interface/billing/ub04_form.php

   1 <?php
   2 /**
   3  * UB04 Claims Form
   4  *
   5  * @package OpenEMR
   6  * @link    http://www.open-emr.org
   7  * @author  Jerry Padgett <sjpadgett@gmail.com>
   8  * @copyright Copyright (c) 2017 Jerry Padgett <sjpadgett@gmail.com>
   9  * @license https://www.gnu.org/licenses/agpl-3.0.en.html GNU Affero General Public License 3
  10  */
  11 /* $isAuthorized tells us if the form is for user UI or claim processing and provides another security check */
  12 if ($isAuthorized !== true) {
  13     require_once("./ub04_dispose.php");
  14     $isAuthorized = 0;
  15     $pid = $_REQUEST['pid'] ? $_REQUEST['pid'] : '0';
  16     $encounter = $_REQUEST['enc'] ? $_REQUEST['enc'] : '0';
  17     $action = $_REQUEST['action'] ? $_REQUEST['action'] : false;
  18     $payerid = $_REQUEST['id'] ? $_REQUEST['id'] : '0';
  19     $imgurl = $GLOBALS['images_static_relative'];
  20     if ($action == 'payer_defaults') {
  21         $ub04id = get_payer_defaults($payerid);
  22     } elseif ($pid && $encounter) {
  23         $ub04id = json_encode(get_ub04_array($pid, $encounter));
  24     } else {
  25         exit(xlt("Sorry! Not Authorized."));
  26     }
  27 } else {
  28     $imgurl = "../../../../public/images";
  29 }
  30
  31 ?>
  32 <!DOCTYPE html >
  33 <html>
  34 <head>
  35 <meta http-equiv="X-UA-Compatible" content="IE=Edge" />
  36 <meta charset="utf-8" />
  37 <?php if ($isAuthorized !== true) {?>
  38 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-3-1-1/index.js"></script>
  39  <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap-3-3-4/dist/css/bootstrap.min.css">
  40  <link href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-ui-1-12-1/themes/base/jquery-ui.min.css" rel="stylesheet" type="text/css" />
  41 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.min.css">
  42 <script src="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap-3-3-4/dist/js/bootstrap.min.js" type="text/javascript"></script>
  43 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/emodal-1-2-65/dist/eModal.js"></script>
  44 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.full.min.js"></script>
  45 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative'] ?>/jquery-ui-1-12-1/jquery-ui.min.js"></script>
  46
  47 <script type="text/javascript">
  48 $( document ).ready(function() {
  49     $( "[title*='DATE']" ).datetimepicker({
  50         <?php $datetimepicker_timepicker = false; ?>
  51         <?php $datetimepicker_showseconds = false; ?>
  52         <?php $datetimepicker_formatInput = false; ?>
  53         <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
  54         <?php echo(",validateOnBlur: false, formatDate: 'mdy', format: 'mdy'") ?>
  55     });
  56
  57     $(".user").on( 'dblclick', function( event ) {
  58         event.preventDefault();
  59         selectUser(this.id,event);
  60     });
  61     $("#dismissHelp").click(function(e){
  62         e.preventDefault();
  63         $('#formHelp').toggle();
  64     });
  65
  66     $( function() {
  67         var cache = {};
  68         $( "[title*='REVENUE CODE']" ).autocomplete({
  69           minLength: 1,
  70           source: function( request, response ) {
  71             var term = request.term;
  72             request.code_group = "revenue_code";
  73             if ( term in cache ) {
  74               response( cache[ term ] );
  75               return;
  76             }
  77             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
  78               cache[ term ] = data;
  79               response( data );
  80             });
  81           }
  82         }).dblclick(function(event) {
  83             $(this).autocomplete('search'," ");
  84         });
  85       });
  86     $( function() {
  87         var cache = {};
  88         $( "[title*='OCCURRENCE CODE']" ).autocomplete({
  89             minLength: 1,
  90             source: function( request, response ) {
  91               var term = request.term;
  92               request.code_group = "occurrence_code";
  93               if ( term in cache ) {
  94                 response( cache[ term ] );
  95                 return;
  96               }
  97               $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
  98                 cache[ term ] = data;
  99                 response( data );
 100               });
 101             }
 102           }).dblclick(function(event) {
 103               $(this).autocomplete('search'," ");
 104           });
 105     });
 106     $( function() {
 107         var cache = {};
 108         $( "[title*='OCCURRENCE SPAN CODE']" ).autocomplete({
 109             minLength: 1,
 110             source: function( request, response ) {
 111               var term = request.term;
 112               request.code_group = "occurrence_span_code";
 113               if ( term in cache ) {
 114                 response( cache[ term ] );
 115                 return;
 116               }
 117               $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 118                 cache[ term ] = data;
 119                 response( data );
 120               });
 121             }
 122           }).dblclick(function(event) {
 123               $(this).autocomplete('search'," ");
 124           });
 125     });
 126     $( function() {
 127         var cache = {};
 128         $( "[title*='VALUE CODE']" ).autocomplete({
 129           minLength: 1,
 130           source: function( request, response ) {
 131             var term = request.term;
 132             request.code_group = "value_codes";
 133             if ( term in cache ) {
 134               response( cache[ term ] );
 135               return;
 136             }
 137             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 138               cache[ term ] = data;
 139               response( data );
 140             });
 141           }
 142         }).dblclick(function(event) {
 143             $(this).autocomplete('search'," ");
 144         });
 145       });
 146     $( function() {
 147         var cache = {};
 148         $( "[title*='CONDITION CODE']" ).autocomplete({
 149           minLength: 1,
 150           source: function( request, response ) {
 151             var term = request.term;
 152             request.code_group = "condition_code";
 153             if ( term in cache ) {
 154               response( cache[ term ] );
 155               return;
 156             }
 157             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 158               cache[ term ] = data;
 159               response( data );
 160             });
 161           }
 162         }).dblclick(function(event) {
 163             $(this).autocomplete('search'," ");
 164         });
 165       });
 166     $( function() {
 167         var cache = {};
 168         $( "[title*='STATUS']" ).autocomplete({
 169           minLength: 1,
 170           source: function( request, response ) {
 171             var term = request.term;
 172             request.code_group = "patient_status_code";
 173             if ( term in cache ) {
 174               response( cache[ term ] );
 175               return;
 176             }
 177             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 178               cache[ term ] = data;
 179               response( data );
 180             });
 181           }
 182         }).dblclick(function(event) {
 183             $(this).autocomplete('search'," ");
 184         });
 185       });
 186
 187     $('form :input').change(function(e){
 188            formChanged = true;
 189            $(this).css("color","red");
 190            return false;
 191     });
 192 });
 193 <?php } else {?>
 194 <script type="text/javascript">
 195 <?php } ?>
 196 var pid;
 197 var encounter;
 198 var align = true;
 199 var isTemplate;
 200 var ub04id = new Array();
 201 payerid = '<?php echo attr($payerid);?>';
 202 pid = <?php echo attr($pid);?>;
 203 encounter = <?php echo attr($encounter);?>;
 204 isTemplate = <?php echo attr(($isAuthorized === true ? $isAuthorized : 0)); ?>;
 205 ub04id = <?php echo $ub04id;?>;
 206
 207 function adjustForm()
 208 {
 209     // cycle trough the input fields
 210     // rem form index i is not same as formid index ii
 211     var inputs = Array.prototype.slice.call(document.forms[0])
 212
 213     Array.prototype.forEach.call(inputs, function(el, i) {
 214         var type = el.getAttribute('type');
 215         var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
 216         var title = el.getAttribute('title')
 217         var max = el.getAttribute('maxlength');
 218         var w = el.clientWidth
 219         var size = w;
 220             if( ta == 'right' ){
 221                 if(title.indexOf("CHARGES") !== -1){
 222                      w = size - 14;
 223                      if(!isTemplate){ w = size - 8; }
 224                 }
 225                 else{
 226                     w = size - 8;
 227                     if(!isTemplate){ w = size - 4; }
 228                 }
 229                 el.style.width = w + 'px'
 230             }
 231         el.style.top = (el.offsetTop+3)+'px'
 232         if( ta == 'left' )
 233             el.style.left = (el.offsetLeft+2)+'px'
 234         var ii = i+1;
 235         if(typeof(ub04id[ii]) != 'undefined' && ub04id[ii] != ""){
 236             var val = ub04id[ii]
 237             if( val.length > max && max > 0 ){
 238                 val = ub04id[ii].substring(0,max);
 239             }
 240             document.getElementById("ub04id"+ ii.toString()).value = val
 241             return;
 242         }
 243  });
 244  return false;
 245 }
 246 <?php if ($isAuthorized !== true) {?>
 247 var formChanged = false;
 248
 249 function rewrite(ub04id){
 250     var inputs = Array.prototype.slice.call(document.forms[0])
 251     Array.prototype.forEach.call(inputs, function(el, i) {
 252         var max = el.getAttribute('maxlength');
 253         var ii = i+1;
 254         if(typeof(ub04id[ii]) != 'undefined'){
 255             var val = ub04id[ii]
 256             if( val.length > max && max > 0 ){
 257                 val = ub04id[ii].substring(0,max);
 258             }
 259             document.getElementById("ub04id"+ ii.toString()).value = val
 260             return;
 261         }
 262     });
 263 }
 264
 265 function cleanUp()
 266 {
 267     if(payerid == '0'){
 268        window.opener.SubmitTheScreen();
 269     }
 270     window.close()
 271 }
 272
 273 function selectUser(formid,event)
 274 {
 275     var title = 'Providers';
 276      var params = {
 277                buttons: [
 278                    { text: 'Cancel', close: true, style: 'default btn-sm'} ],
 279                //size: eModal.size.sm,
 280                subtitle: 'Provider Info.',
 281                title: title,
 282                useBin: false,
 283                url: './ub04_helpers.php?action=user_select&formid=' + encodeURIComponent(formid)
 284            };
 285        return eModal.ajax(params)
 286            .then(function () { });
 287 }
 288
 289 function updateProvider(formid, selected)
 290 {
 291     document.getElementById(formid).value = selected.npi;
 292     if(formid == 'ub04id379'){
 293         document.getElementById('ub04id388').value = selected.lname;
 294         document.getElementById('ub04id389').value = selected.fname;
 295         document.getElementById('ub04id289').value = selected.taxonomy;
 296     }
 297     else if(formid == 'ub04id390'){
 298         document.getElementById('ub04id400').value = selected.lname;
 299         document.getElementById('ub04id401').value = selected.fname;
 300         document.getElementById('ub04id296').value = selected.taxonomy;
 301     }
 302     else if(formid == 'ub04id406'){
 303         document.getElementById('ub04id413').value = selected.lname;
 304         document.getElementById('ub04id414').value = selected.fname;
 305         document.getElementById('ub04id303').value = selected.taxonomy;
 306     }
 307     else if(formid == 'ub04id420'){
 308         document.getElementById('ub04id427').value = selected.lname;
 309         document.getElementById('ub04id428').value = selected.fname;
 310     }
 311     return false;
 312 }
 313 function disposeSave(action)
 314 {
 315     var htmlout = "";
 316     var inputs;
 317     var slice = Array.prototype.slice;
 318     inputs = slice.call(document.forms[0])
 319     Array.prototype.forEach.call(inputs, function(el, i) {
 320         var ii = i+1;
 321         var tmp = document.getElementById("ub04id"+ ii.toString()).value;
 322         if(tmp){
 323             ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
 324         }
 325     });
 326     ub04idSave = JSON.stringify(ub04id);
 327     var qstr = param({ handler: 'edit_save',pid:pid,encounter:encounter,action:action,ub04id:ub04idSave });
 328     location.href='ub04_dispose.php?'+qstr;
 329 }
 330
 331 function postClaim(action)
 332 {
 333     var inputs;
 334     var c = [];
 335     var slice = Array.prototype.slice;
 336     inputs = slice.call(document.forms[0])
 337     Array.prototype.forEach.call(inputs, function(el, i) {
 338         var ii = i+1;
 339         var tmp = document.getElementById("ub04id"+ ii.toString()).value;
 340         if(tmp){
 341             var row = el.offsetTop.toString();
 342             var col = el.offsetLeft.toString();
 343             var max = el.getAttribute('maxlength');
 344             var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
 345             var w = window.getComputedStyle(el,null).getPropertyValue("width");
 346             var ob = {fld:ii,top:row,left:col,max:max,align:ta,width:w}
 347             c.push(ob)
 348             ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
 349         }
 350     });
 351     var cj = JSON.stringify(c)
 352     ub04idSave = JSON.stringify(ub04id);
 353     var xhr = new XMLHttpRequest();
 354     xhr.open('POST', 'ub04_dispose.php');
 355     xhr.setRequestHeader("Content-Type", "application/x-www-form-urlencoded");
 356     xhr.onload = function() {
 357         if (xhr.status === 200) {
 358             console.log(this.responseText ? this.responseText : 'no response');
 359             if(this.responseText == 'done')
 360                 alert("<?php echo xls("Save Completed")?>");
 361         }
 362     };
 363     if(action == 'payer_save'){
 364         var qs = param({handler:action,payerid:payerid,ub04id: ub04idSave})
 365     }
 366     else if(action == 'batch_save'){
 367         var qs = param({handler:action,pid:pid,encounter:encounter,ub04id:ub04idSave,loc:cj})
 368     }
 369     xhr.send(qs);
 370 }
 371
 372 function param(object)
 373 {
 374     var encodedString = '';
 375     for (var prop in object) {
 376         if (object.hasOwnProperty(prop)) {
 377             if (encodedString.length > 0) {
 378                 encodedString += '&';
 379             }
 380             encodedString += encodeURI(prop + '=' + object[prop]);
 381         }
 382     }
 383     return encodedString;
 384 }
 385
 386 var scale = 1.25;
 387 function myZoom()
 388 {
 389     var el = document.getElementById('p1');
 390     scale += 0.05;
 391     if(scale > 1.25) scale = 1.0;
 392     el.style.transform = 'scale(' + scale + ')';
 393 }
 394
 395 function resetClaim(){
 396     var msg = '<?php echo xlt('This action will reset your claim!') . '\n' . xlt('Click OK if you are sure.')?>';
 397     var yn = confirm(msg);
 398     if (yn != true) {
 399         return false;
 400     }
 401     $.ajax({
 402         type: 'GET',
 403         url: 'ub04_dispose.php',
 404         data: {handler:'reset_claim',pid:pid,encounter:encounter},
 405         dataType: 'json',
 406         success: function( rtn ) {
 407           ub04id = rtn;
 408           document.getElementById('ub04Data').reset();
 409           rewrite(ub04id);
 410         }
 411     });
 412 }
 413
 414 <?php } ?>
 415 </script>
 416
 417 <style>
 418 .container {
 419 text-align:center;
 420 }
 421
 422 .ui-autocomplete {max-height: 250px; max-width: 25%; width: 50%; overflow-y: auto; overflow-x: hidden;}
 423
 424 input{
 425     z-index:2;
 426     text-transform: uppercase;
 427     position: absolute; border-width:0px;
 428     height:14px; color: rgb(0,0,0);
 429     background: transparent; border-color:transparent;
 430     font:normal 10pt 'Times New Roman', Times, serif;
 431 }
 432
 433 textarea{
 434     z-index:2;
 435     text-transform: uppercase;
 436     position: absolute; border-width:0px;
 437     color: rgb(0,0,0);
 438     background: transparent; border-color:transparent;
 439     font:normal 10pt 'Times New Roman', Times, serif;
 440 }
 441
 442 input:focus{color: blue !important;}
 443
 444 body {
 445     padding: 0px;
 446     margin-top: 35px;
 447     margin-bottom: 35px;
 448     background-color: lightgrey;
 449 }
 450
 451 #p1 {
 452     transform: scale(1.2);
 453     transform-origin: top center;
 454     margin-top: 0px;
 455     margin-left: auto;
 456     margin-right: auto;
 457 }
 458
 459 #menu {
 460     text-align: center;
 461     z-index: 9999;
 462     background-color: ghostwhite;
 463     position: fixed;
 464     padding:5px 5px 5px 5px;
 465     margin-left: auto;
 466     margin-right: auto;
 467     /* opacity: 0.8; */
 468     top: 0px;
 469 }
 470
 471 @media print {
 472 .datepicker{
 473     border-color:transparent !important;
 474     background-color:transparent !important;
 475 }
 476 .user{
 477     background-color:transparent !important;
 478     border-color:transparent !important;
 479 }
 480 body {
 481     padding: 0px;
 482     margin: 0px;
 483     background-color: #fff;
 484 }
 485 .formhide {
 486     display: none;
 487 }
 488 #p1 {
 489     margin-top: 0px;
 490     margin-left: 0px;
 491     margin-right: 0px;
 492 }
 493 input{
 494     z-index:2;
 495     text-transform: uppercase;
 496     position: absolute; border-width:0px;
 497     height:14px; color: rgb(0,0,0);
 498     background: transparent; border-color:transparent;
 499     font:normal 10pt 'Times New Roman', Times, serif;
 500 }
 501 textarea{
 502     z-index:2;
 503     text-transform: uppercase;
 504     position: absolute; border-width:0px;
 505     color: rgb(0,0,0);
 506     background: transparent; border-color:transparent;
 507     font:normal 10pt 'Times New Roman', Times, serif;
 508 }
 509 }
 510
 511 #ub04id1{ left:301px; top:19px; width:264px;  text-align:left;}
 512 #ub04id2{ left:26px;  top:19px; width:264px;  text-align:left;}
 513 #ub04id3{ left:599px; top:19px; width:263px;  text-align:left;}
 514 #ub04id4{ left:26px;  top:37px; width:264px;  text-align:left;}
 515 #ub04id5{ left:301px; top:37px; width:264px;  text-align:left;}
 516 #ub04id6{ left:599px; top:37px; width:263px;  text-align:left;}
 517 #ub04id7{ left:862px; top:37px; width:57px;  text-align:center;}
 518 #ub04id8{ left:26px;  top:57px; width:264px;  text-align:left;}
 519 #ub04id9{ left:301px; top:57px; width:264px;  text-align:left;}
 520 #ub04id10{left:26px;  top:74px; width:264px;  text-align:left;}
 521 #ub04id11{left:301px; top:74px; width:264px;  text-align:left;}
 522 #ub04id12{left:567px; top:74px; width:110px;  text-align:left;}
 523 #ub04id13{left:675px; top:74px; width:77px;  text-align:center;}
 524 #ub04id14{left:753px; top:74px; width:77px;  text-align:center;}
 525 #ub04id15{resize:none; left:842px; top:55px; width:77px; height:32px; color: rgb(0,0,0); text-align:left;}
 526 #ub04id16{left:138px; top:92px; width:208px;  text-align:left;}
 527 #ub04id17{left:468px; top:92px; width:451px;  text-align:left;}
 528 #ub04id18{left:28px;  top:110px; width:318px;  text-align:left;}
 529 #ub04id19{left:358px; top:110px; width:352px;  text-align:left;}
 530 #ub04id20{left:720px; top:110px; width:34px;  text-align:left;}
 531 #ub04id21{left:764px; top:110px; width:110px;  text-align:left;}
 532 #ub04id22{left:885px; top:110px; width:34px;  text-align:left;}
 533 #ub04id23{left:15px;  top:147px; width:99px;  text-align:right;}
 534 #ub04id24{left:115px; top:147px; width:34px;  text-align:center;}
 535 #ub04id25{left:148px; top:147px; width:66px;  text-align:right;}
 536 #ub04id26{left:214px; top:147px; width:32px;  text-align:center;}
 537 #ub04id27{left:246px; top:147px; width:34px;  text-align:center;}
 538 #ub04id28{left:280px; top:147px; width:32px;  text-align:center;}
 539 #ub04id29{left:312px; top:147px; width:34px;  text-align:center;}
 540 #ub04id30{left:345px; top:147px; width:34px;  text-align:right;}
 541 #ub04id31{left:378px; top:147px; width:34px;  text-align:center;}
 542 #ub04id32{left:411px; top:147px; width:34px;  text-align:center;}
 543 #ub04id33{left:445px; top:147px; width:34px;  text-align:center;}
 544 #ub04id34{left:477px; top:147px; width:34px;  text-align:center;}
 545 #ub04id35{left:510px; top:147px; width:34px;  text-align:center;}
 546 #ub04id36{left:543px; top:147px; width:34px;  text-align:center;}
 547 #ub04id37{left:576px; top:147px; width:34px;  text-align:center;}
 548 #ub04id38{left:610px; top:147px; width:34px;  text-align:center;}
 549 #ub04id39{left:643px; top:147px; width:34px;  text-align:center;}
 550 #ub04id40{left:675px; top:147px; width:34px;  text-align:center;}
 551 #ub04id41{left:709px; top:147px; width:32px;  text-align:center;}
 552 #ub04id42{left:741px; top:147px; width:37px;  text-align:center;}
 553 #ub04id43{left:778px; top:147px; width:141px;  text-align:left;}
 554 #ub04id44{left:15px;  top:184px; width:32px;  text-align:center;}
 555 #ub04id45{left:49px;  top:184px; width:77px;  text-align:right;}
 556 #ub04id46{left:125px; top:184px; width:32px;  text-align:center;}
 557 #ub04id47{left:159px; top:184px; width:77px;  text-align:right;}
 558 #ub04id48{left:235px; top:184px; width:32px;  text-align:center;}
 559 #ub04id49{left:269px; top:184px; width:77px;  text-align:right;}
 560 #ub04id50{left:345px; top:184px; width:34px;  text-align:center;}
 561 #ub04id51{left:379px; top:184px; width:77px;  text-align:right;}
 562 #ub04id52{left:455px; top:184px; width:34px;  text-align:center;}
 563 #ub04id53{left:489px; top:184px; width:77px;  text-align:right;}
 564 #ub04id54{left:567px; top:184px; width:77px;  text-align:right;}
 565 #ub04id55{left:643px; top:184px; width:32px;  text-align:center;}
 566 #ub04id56{left:677px; top:184px; width:77px;  text-align:right;}
 567 #ub04id57{left:755px; top:184px; width:77px;  text-align:right;}
 568 #ub04id58{left:831px; top:184px; width:87px;  text-align:center;}
 569 #ub04id59{left:15px;  top:202px; width:32px;  text-align:center;}
 570 #ub04id60{left:49px;  top:202px; width:77px;  text-align:right;}
 571 #ub04id61{left:125px; top:202px; width:32px;  text-align:center;}
 572 #ub04id62{left:159px; top:202px; width:77px;  text-align:right;}
 573 #ub04id63{left:235px; top:202px; width:32px;  text-align:center;}
 574 #ub04id64{left:269px; top:202px; width:77px;  text-align:right;}
 575 #ub04id65{left:345px; top:202px; width:34px;  text-align:center;}
 576 #ub04id66{left:379px; top:202px; width:77px;  text-align:right;}
 577 #ub04id67{left:455px; top:202px; width:34px;  text-align:center;}
 578 #ub04id68{left:489px; top:202px; width:77px;  text-align:right;}
 579 #ub04id69{left:567px; top:202px; width:77px;  text-align:right;}
 580 #ub04id70{left:643px; top:202px; width:32px;  text-align:center;}
 581 #ub04id71{left:677px; top:202px; width:77px;  text-align:right;}
 582 #ub04id72{left:755px; top:202px; width:77px;  text-align:right;}
 583 #ub04id73{left:831px; top:202px; width:87px;  text-align:center;}
 584 #ub04id74{left:489px; top:240px; width:32px;  text-align:center;}
 585 #ub04id75{left:523px; top:240px; width:110px;  text-align:right;}
 586 #ub04id76{left:631px; top:240px; width:34px;  text-align:center;}
 587 #ub04id77{left:666px; top:240px; width:110px;  text-align:right;}
 588 #ub04id78{left:775px; top:240px; width:34px;  text-align:center;}
 589 #ub04id79{left:808px; top:240px; width:110px;  text-align:right;}
 590 #ub04id80{left:489px; top:258px; width:32px;  text-align:center;}
 591 #ub04id81{left:523px; top:258px; width:110px;  text-align:right;}
 592 #ub04id82{left:631px; top:258px; width:34px;  text-align:center;}
 593 #ub04id83{left:666px; top:258px; width:110px;  text-align:right;}
 594 #ub04id84{left:775px; top:258px; width:34px;  text-align:center;}
 595 #ub04id85{left:808px; top:258px; width:110px;  text-align:right;}
 596 #ub04id86{left:489px; top:275px; width:32px;  text-align:center;}
 597 #ub04id87{left:523px; top:275px; width:110px;  text-align:right;}
 598 #ub04id88{left:631px; top:275px; width:34px;  text-align:center;}
 599 #ub04id89{left:666px; top:275px; width:110px;  text-align:right;}
 600 #ub04id90{left:775px; top:275px; width:34px;  text-align:center;}
 601 #ub04id91{left:808px; top:275px; width:110px;  text-align:right;}
 602 #ub04id92{left:489px; top:294px; width:32px;  text-align:center;}
 603 #ub04id93{left:523px; top:294px; width:110px;  text-align:right;}
 604 #ub04id94{left:631px; top:294px; width:34px;  text-align:center;}
 605 #ub04id95{left:666px; top:294px; width:110px;  text-align:right;}
 606 #ub04id96{left:775px; top:294px; width:34px;  text-align:center;}
 607 #ub04id97{left:808px; top:294px; width:110px;  text-align:right;}
 608 #ub04id98{z-index:2; resize:none; position: absolute; left:31px; top:220px; width:448px; height:87px; color: rgb(0,0,0); text-align:left;}
 609 #ub04id99{left:15px;  top:332px; width:52px;  text-align:center;}
 610 #ub04id100{left:67px;  top:332px; width:274px;  text-align:left;}
 611 #ub04id101{left:342px; top:332px; width:164px;  text-align:center;}
 612 #ub04id102{left:507px; top:332px; width:77px;  text-align:right;}
 613 #ub04id103{left:585px; top:332px; width:86px;  text-align:right;}
 614 #ub04id104{left:672px; top:332px; width:110px;  text-align:right;}
 615 #ub04id105{left:782px; top:332px; width:109px;  text-align:right;}
 616 #ub04id106{left:891px; top:332px; width:28px;  text-align:center;}
 617 #ub04id107{left:15px;  top:349px; width:52px;  text-align:center;}
 618 #ub04id108{left:67px;  top:349px; width:274px;  text-align:left;}
 619 #ub04id109{left:342px; top:349px; width:164px;  text-align:center;}
 620 #ub04id110{left:507px; top:349px; width:77px;  text-align:right;}
 621 #ub04id111{left:585px; top:349px; width:86px;  text-align:right;}
 622 #ub04id112{left:672px; top:349px; width:110px;  text-align:right;}
 623 #ub04id113{left:782px; top:349px; width:109px;  text-align:right;}
 624 #ub04id114{left:891px; top:349px; width:28px;  text-align:center;}
 625 #ub04id115{left:15px;  top:368px; width:52px;  text-align:center;}
 626 #ub04id116{left:67px;  top:368px; width:274px;  text-align:left;}
 627 #ub04id117{left:342px; top:368px; width:164px;  text-align:center;}
 628 #ub04id118{left:507px; top:368px; width:77px;  text-align:right;}
 629 #ub04id119{left:585px; top:368px; width:86px;  text-align:right;}
 630 #ub04id120{left:672px; top:368px; width:110px;  text-align:right;}
 631 #ub04id121{left:782px; top:368px; width:109px;  text-align:right;}
 632 #ub04id122{left:891px; top:368px; width:28px;  text-align:center;}
 633 #ub04id123{left:15px;  top:385px; width:52px;  text-align:center;}
 634 #ub04id124{left:67px;  top:385px; width:274px;  text-align:left;}
 635 #ub04id125{left:342px; top:385px; width:164px;  text-align:center;}
 636 #ub04id126{left:507px; top:385px; width:77px;  text-align:right;}
 637 #ub04id127{left:585px; top:385px; width:86px;  text-align:right;}
 638 #ub04id128{left:672px; top:385px; width:110px;  text-align:right;}
 639 #ub04id129{left:782px; top:385px; width:109px;  text-align:right;}
 640 #ub04id130{left:891px; top:385px; width:28px;  text-align:center;}
 641 #ub04id131{left:15px;  top:404px; width:52px;  text-align:center;}
 642 #ub04id132{left:67px;  top:404px; width:274px;  text-align:left;}
 643 #ub04id133{left:342px; top:404px; width:164px;  text-align:center;}
 644 #ub04id134{left:507px; top:404px; width:77px;  text-align:right;}
 645 #ub04id135{left:585px; top:404px; width:86px;  text-align:right;}
 646 #ub04id136{left:672px; top:404px; width:110px;  text-align:right;}
 647 #ub04id137{left:782px; top:404px; width:109px;  text-align:right;}
 648 #ub04id138{left:891px; top:404px; width:28px;  text-align:center;}
 649 #ub04id139{left:15px;  top:422px; width:52px;  text-align:center;}
 650 #ub04id140{left:67px;  top:422px; width:274px;  text-align:left;}
 651 #ub04id141{left:342px; top:422px; width:164px;  text-align:center;}
 652 #ub04id142{left:507px; top:422px; width:77px;  text-align:right;}
 653 #ub04id143{left:585px; top:422px; width:86px;  text-align:right;}
 654 #ub04id144{left:672px; top:422px; width:110px;  text-align:right;}
 655 #ub04id145{left:782px; top:422px; width:109px;  text-align:right;}
 656 #ub04id146{left:891px; top:422px; width:28px;  text-align:center;}
 657 #ub04id147{left:15px;  top:440px; width:52px;  text-align:center;}
 658 #ub04id148{left:67px;  top:440px; width:274px;  text-align:left;}
 659 #ub04id149{left:342px; top:440px; width:164px;  text-align:center;}
 660 #ub04id150{left:507px; top:440px; width:77px;  text-align:right;}
 661 #ub04id151{left:585px; top:440px; width:86px;  text-align:right;}
 662 #ub04id152{left:672px; top:440px; width:110px;  text-align:right;}
 663 #ub04id153{left:782px; top:440px; width:109px;  text-align:right;}
 664 #ub04id154{left:891px; top:440px; width:28px;  text-align:center;}
 665 #ub04id155{left:15px;  top:459px; width:52px;  text-align:center;}
 666 #ub04id156{left:67px;  top:459px; width:274px;  text-align:left;}
 667 #ub04id157{left:342px; top:459px; width:164px;  text-align:center;}
 668 #ub04id158{left:507px; top:459px; width:77px;  text-align:right;}
 669 #ub04id159{left:585px; top:459px; width:86px;  text-align:right;}
 670 #ub04id160{left:672px; top:459px; width:110px;  text-align:right;}
 671 #ub04id161{left:782px; top:459px; width:109px;  text-align:right;}
 672 #ub04id162{left:891px; top:459px; width:28px;  text-align:center;}
 673 #ub04id163{left:15px;  top:477px; width:52px;  text-align:center;}
 674 #ub04id164{left:67px;  top:477px; width:274px;  text-align:left;}
 675 #ub04id165{left:342px; top:477px; width:164px;  text-align:center;}
 676 #ub04id166{left:507px; top:477px; width:77px;  text-align:right;}
 677 #ub04id167{left:585px; top:477px; width:86px;  text-align:right;}
 678 #ub04id168{left:672px; top:477px; width:110px;  text-align:right;}
 679 #ub04id169{left:782px; top:477px; width:109px;  text-align:right;}
 680 #ub04id170{left:891px; top:477px; width:28px;  text-align:center;}
 681 #ub04id171{left:15px;  top:495px; width:52px;  text-align:center;}
 682 #ub04id172{left:67px;  top:495px; width:274px;  text-align:left;}
 683 #ub04id173{left:342px; top:495px; width:164px;  text-align:center;}
 684 #ub04id174{left:507px; top:495px; width:77px;  text-align:right;}
 685 #ub04id175{left:585px; top:495px; width:86px;  text-align:right;}
 686 #ub04id176{left:672px; top:495px; width:110px;  text-align:right;}
 687 #ub04id177{left:782px; top:495px; width:109px;  text-align:right;}
 688 #ub04id178{left:891px; top:495px; width:28px;  text-align:center;}
 689 #ub04id179{left:15px;  top:514px; width:52px;  text-align:center;}
 690 #ub04id180{left:67px;  top:514px; width:274px;  text-align:left;}
 691 #ub04id181{left:342px; top:514px; width:164px;  text-align:center;}
 692 #ub04id182{left:507px; top:514px; width:77px;  text-align:right;}
 693 #ub04id183{left:585px; top:514px; width:86px;  text-align:right;}
 694 #ub04id184{left:672px; top:514px; width:110px;  text-align:right;}
 695 #ub04id185{left:782px; top:514px; width:109px;  text-align:right;}
 696 #ub04id186{left:891px; top:514px; width:28px;  text-align:center;}
 697 #ub04id187{left:15px;  top:532px; width:52px;  text-align:center;}
 698 #ub04id188{left:67px;  top:532px; width:274px;  text-align:left;}
 699 #ub04id189{left:342px; top:532px; width:164px;  text-align:center;}
 700 #ub04id190{left:507px; top:532px; width:77px;  text-align:right;}
 701 #ub04id191{left:585px; top:532px; width:86px;  text-align:right;}
 702 #ub04id192{left:672px; top:532px; width:110px;  text-align:right;}
 703 #ub04id193{left:782px; top:532px; width:109px;  text-align:right;}
 704 #ub04id194{left:891px; top:532px; width:28px;  text-align:center;}
 705 #ub04id195{left:15px;  top:550px; width:52px;  text-align:center;}
 706 #ub04id196{left:67px;  top:550px; width:274px;  text-align:left;}
 707 #ub04id197{left:342px; top:550px; width:164px;  text-align:center;}
 708 #ub04id198{left:507px; top:550px; width:77px;  text-align:right;}
 709 #ub04id199{left:585px; top:550px; width:86px;  text-align:right;}
 710 #ub04id200{left:672px; top:550px; width:110px;  text-align:right;}
 711 #ub04id201{left:782px; top:550px; width:109px;  text-align:right;}
 712 #ub04id202{left:891px; top:550px; width:28px;  text-align:center;}
 713 #ub04id203{left:15px;  top:569px; width:52px;  text-align:center;}
 714 #ub04id204{left:67px;  top:569px; width:274px;  text-align:left;}
 715 #ub04id205{left:342px; top:569px; width:164px;  text-align:center;}
 716 #ub04id206{left:507px; top:569px; width:77px;  text-align:right;}
 717 #ub04id207{left:585px; top:569px; width:86px;  text-align:right;}
 718 #ub04id208{left:672px; top:569px; width:110px;  text-align:right;}
 719 #ub04id209{left:782px; top:569px; width:109px;  text-align:right;}
 720 #ub04id210{left:891px; top:569px; width:28px;  text-align:center;}
 721 #ub04id211{left:15px;  top:587px; width:52px;  text-align:center;}
 722 #ub04id212{left:67px;  top:587px; width:274px;  text-align:left;}
 723 #ub04id213{left:342px; top:587px; width:164px;  text-align:center;}
 724 #ub04id214{left:507px; top:587px; width:77px;  text-align:right;}
 725 #ub04id215{left:585px; top:587px; width:86px;  text-align:right;}
 726 #ub04id216{left:672px; top:587px; width:110px;  text-align:right;}
 727 #ub04id217{left:782px; top:587px; width:109px;  text-align:right;}
 728 #ub04id218{left:891px; top:587px; width:28px;  text-align:center;}
 729 #ub04id219{left:15px;  top:605px; width:52px;  text-align:center;}
 730 #ub04id220{left:67px;  top:605px; width:274px;  text-align:left;}
 731 #ub04id221{left:342px; top:605px; width:164px;  text-align:center;}
 732 #ub04id222{left:507px; top:605px; width:77px;  text-align:right;}
 733 #ub04id223{left:585px; top:605px; width:86px;  text-align:right;}
 734 #ub04id224{left:672px; top:605px; width:110px;  text-align:right;}
 735 #ub04id225{left:782px; top:605px; width:109px;  text-align:right;}
 736 #ub04id226{left:891px; top:605px; width:28px;  text-align:center;}
 737 #ub04id227{left:15px;  top:624px; width:52px;  text-align:center;}
 738 #ub04id228{left:67px;  top:624px; width:274px;  text-align:left;}
 739 #ub04id229{left:342px; top:624px; width:164px;  text-align:center;}
 740 #ub04id230{left:507px; top:624px; width:77px;  text-align:right;}
 741 #ub04id231{left:585px; top:624px; width:86px;  text-align:right;}
 742 #ub04id232{left:672px; top:624px; width:110px;  text-align:right;}
 743 #ub04id233{left:782px; top:624px; width:109px;  text-align:right;}
 744 #ub04id234{left:891px; top:624px; width:28px;  text-align:center;}
 745 #ub04id235{left:15px;  top:642px; width:52px;  text-align:center;}
 746 #ub04id236{left:67px;  top:642px; width:274px;  text-align:left;}
 747 #ub04id237{left:342px; top:642px; width:164px;  text-align:center;}
 748 #ub04id238{left:507px; top:642px; width:77px;  text-align:right;}
 749 #ub04id239{left:585px; top:642px; width:86px;  text-align:right;}
 750 #ub04id240{left:672px; top:642px; width:110px;  text-align:right;}
 751 #ub04id241{left:782px; top:642px; width:109px;  text-align:right;}
 752 #ub04id242{left:891px; top:642px; width:28px;  text-align:center;}
 753 #ub04id243{left:15px;  top:660px; width:52px;  text-align:center;}
 754 #ub04id244{left:67px;  top:660px; width:274px;  text-align:left;}
 755 #ub04id245{left:342px; top:660px; width:164px;  text-align:center;}
 756 #ub04id246{left:507px; top:660px; width:77px;  text-align:right;}
 757 #ub04id247{left:585px; top:660px; width:86px;  text-align:right;}
 758 #ub04id248{left:672px; top:660px; width:110px;  text-align:right;}
 759 #ub04id249{left:782px; top:660px; width:109px;  text-align:right;}
 760 #ub04id250{left:891px; top:660px; width:28px;  text-align:center;}
 761 #ub04id251{left:15px;  top:679px; width:52px;  text-align:center;}
 762 #ub04id252{left:67px;  top:679px; width:274px;  text-align:left;}
 763 #ub04id253{left:342px; top:679px; width:164px;  text-align:center;}
 764 #ub04id254{left:507px; top:679px; width:77px;  text-align:right;}
 765 #ub04id255{left:585px; top:679px; width:86px;  text-align:right;}
 766 #ub04id256{left:672px; top:679px; width:110px;  text-align:right;}
 767 #ub04id257{left:782px; top:679px; width:109px;  text-align:right;}
 768 #ub04id258{left:891px; top:679px; width:28px;  text-align:center;}
 769 #ub04id259{left:15px;  top:697px; width:52px;  text-align:center;}
 770 #ub04id260{left:67px;  top:697px; width:274px;  text-align:left;}
 771 #ub04id261{left:342px; top:697px; width:164px;  text-align:center;}
 772 #ub04id262{left:507px; top:697px; width:77px;  text-align:right;}
 773 #ub04id263{left:585px; top:697px; width:86px;  text-align:right;}
 774 #ub04id264{left:672px; top:697px; width:110px;  text-align:right;}
 775 #ub04id265{left:782px; top:697px; width:109px;  text-align:right;}
 776 #ub04id266{left:891px; top:697px; width:28px;  text-align:center;}
 777 #ub04id267{left:15px;  top:715px; width:52px;  text-align:center;}
 778 #ub04id268{left:67px;  top:715px; width:274px;  text-align:left;}
 779 #ub04id269{left:342px; top:715px; width:164px;  text-align:center;}
 780 #ub04id270{left:507px; top:715px; width:77px;  text-align:right;}
 781 #ub04id271{left:585px; top:715px; width:86px;  text-align:right;}
 782 #ub04id272{left:672px; top:715px; width:110px;  text-align:right;}
 783 #ub04id273{left:782px; top:715px; width:109px;  text-align:right;}
 784 #ub04id274{left:891px; top:715px; width:28px;  text-align:center;}
 785 #ub04id275{left:15px;  top:734px; width:52px;  text-align:center;}
 786 #ub04id276{left:118px; top:734px; width:32px;  text-align:center;}
 787 #ub04id277{left:182px; top:734px; width:32px;  text-align:center;}
 788 #ub04id278{left:507px; top:734px; width:77px;  text-align:center;}
 789 #ub04id279{left:672px; top:734px; width:110px;  text-align:right;}
 790 #ub04id280{left:782px; top:734px; width:109px;  text-align:right;}
 791 #ub04id281{left:891px; top:734px; width:28px;  text-align:center;}
 792 #ub04id282{left:753px; top:752px; width:165px;  text-align:left;}
 793 #ub04id283{left:15px;  top:770px; width:252px;  text-align:left;}
 794 #ub04id284{left:269px; top:770px; width:164px;  text-align:left;}
 795 #ub04id285{left:434px; top:770px; width:22px;  text-align:left;}
 796 #ub04id286{left:468px; top:770px; width:20px;  text-align:left;}
 797 #ub04id287{left:489px; top:770px; width:110px;  text-align:right;}
 798 #ub04id288{left:599px; top:770px; width:121px;  text-align:right;}
 799 #ub04id289{left:753px; top:770px; width:165px;  text-align:left;}
 800 #ub04id290{left:15px;  top:789px; width:252px;  text-align:left;}
 801 #ub04id291{left:269px; top:789px; width:164px;  text-align:left;}
 802 #ub04id292{left:434px; top:789px; width:22px;  text-align:left;}
 803 #ub04id293{left:468px; top:789px; width:20px;  text-align:left;}
 804 #ub04id294{left:489px; top:789px; width:110px;  text-align:right;}
 805 #ub04id295{left:599px; top:789px; width:121px;  text-align:right;}
 806 #ub04id296{left:753px; top:789px; width:165px;  text-align:left;}
 807 #ub04id297{left:15px;  top:807px; width:252px;  text-align:left;}
 808 #ub04id298{left:269px; top:807px; width:164px;  text-align:left;}
 809 #ub04id299{left:434px; top:807px; width:22px;  text-align:left;}
 810 #ub04id300{left:468px; top:807px; width:20px;  text-align:left;}
 811 #ub04id301{left:489px; top:807px; width:110px;  text-align:right;}
 812 #ub04id302{left:599px; top:807px; width:121px;  text-align:right;}
 813 #ub04id303{left:753px; top:807px; width:165px;  text-align:left;}
 814 #ub04id304{left:15px;  top:845px; width:286px;  text-align:left;}
 815 #ub04id305{left:301px; top:845px; width:32px;  text-align:left;}
 816 #ub04id306{left:333px; top:845px; width:220px;  text-align:left;}
 817 #ub04id307{left:555px; top:845px; width:165px;  text-align:left;}
 818 #ub04id308{left:720px; top:845px; width:199px;  text-align:left;}
 819 #ub04id309{left:15px;  top:862px; width:286px;  text-align:left;}
 820 #ub04id310{left:301px; top:862px; width:32px;  text-align:left;}
 821 #ub04id311{left:333px; top:862px; width:220px;  text-align:left;}
 822 #ub04id312{left:555px; top:862px; width:165px;  text-align:left;}
 823 #ub04id313{left:720px; top:862px; width:199px;  text-align:left;}
 824 #ub04id314{left:15px;  top:880px; width:286px;  text-align:left;}
 825 #ub04id315{left:301px; top:880px; width:32px;  text-align:left;}
 826 #ub04id316{left:333px; top:880px; width:220px;  text-align:left;}
 827 #ub04id317{left:555px; top:880px; width:165px;  text-align:left;}
 828 #ub04id318{left:720px; top:880px; width:199px;  text-align:left;}
 829 #ub04id319{left:15px;  top:917px; width:341px;  text-align:left;}
 830 #ub04id320{left:358px; top:917px; width:286px;  text-align:left;}
 831 #ub04id321{left:643px; top:917px; width:275px;  text-align:left;}
 832 #ub04id322{left:15px;  top:935px; width:341px;  text-align:left;}
 833 #ub04id323{left:358px; top:935px; width:286px;  text-align:left;}
 834 #ub04id324{left:643px; top:935px; width:275px;  text-align:left;}
 835 #ub04id325{left:15px;  top:954px; width:341px;  text-align:left;}
 836 #ub04id326{left:358px; top:954px; width:286px;  text-align:left;}
 837 #ub04id327{left:643px; top:954px; width:275px;  text-align:left;}
 838 #ub04id328{left:28px;  top:972px; width:77px;  text-align:left;}
 839 #ub04id329{left:106px; top:972px; width:11px;  text-align:center;}
 840 #ub04id330{left:115px; top:972px; width:78px;  text-align:left;}
 841 #ub04id331{left:193px; top:972px; width:12px;  text-align:center;}
 842 #ub04id332{left:203px; top:972px; width:78px;  text-align:left;}
 843 #ub04id333{left:280px; top:972px; width:12px;  text-align:center;}
 844 #ub04id334{left:290px; top:972px; width:78px;  text-align:left;}
 845 #ub04id335{left:368px; top:972px; width:12px;  text-align:center;}
 846 #ub04id336{left:381px; top:972px; width:77px;  text-align:left;}
 847 #ub04id337{left:457px; top:972px; width:11px;  text-align:center;}
 848 #ub04id338{left:468px; top:972px; width:77px;  text-align:left;}
 849 #ub04id339{left:544px; top:972px; width:12px;  text-align:center;}
 850 #ub04id340{left:556px; top:972px; width:77px;  text-align:left;}
 851 #ub04id341{left:633px; top:972px; width:12px;  text-align:center;}
 852 #ub04id342{left:643px; top:972px; width:78px;  text-align:left;}
 853 #ub04id343{left:721px; top:972px; width:11px;  text-align:center;}
 854 #ub04id344{left:732px; top:972px; width:78px;  text-align:left;}
 855 #ub04id345{left:810px; top:972px; width:11px;  text-align:center;}
 856 #ub04id346{left:833px; top:972px; width:86px;  text-align:left;}
 857 #ub04id347{left:15px;  top:990px; width:11px;  text-align:center;}
 858 #ub04id348{left:28px;  top:990px; width:77px;  text-align:left;}
 859 #ub04id349{left:106px; top:990px; width:11px;  text-align:center;}
 860 #ub04id350{left:115px; top:990px; width:78px;  text-align:left;}
 861 #ub04id351{left:193px; top:990px; width:12px;  text-align:center;}
 862 #ub04id352{left:203px; top:990px; width:78px;  text-align:left;}
 863 #ub04id353{left:280px; top:990px; width:12px;  text-align:center;}
 864 #ub04id354{left:290px; top:990px; width:78px;  text-align:left;}
 865 #ub04id355{left:368px; top:990px; width:12px;  text-align:center;}
 866 #ub04id356{left:381px; top:990px; width:77px;  text-align:left;}
 867 #ub04id357{left:457px; top:990px; width:11px;  text-align:center;}
 868 #ub04id358{left:468px; top:990px; width:78px;  text-align:left;}
 869 #ub04id359{left:544px; top:990px; width:12px;  text-align:center;}
 870 #ub04id360{left:556px; top:990px; width:77px;  text-align:left;}
 871 #ub04id361{left:633px; top:990px; width:12px;  text-align:center;}
 872 #ub04id362{left:643px; top:990px; width:78px;  text-align:left;}
 873 #ub04id363{left:732px; top:990px; width:78px;  text-align:left;}
 874 #ub04id364{left:810px; top:990px; width:11px;  text-align:center;}
 875 #ub04id365{left:821px; top:990px; width:98px;  text-align:left;}
 876 #ub04id366{left:721px; top:990px; width:11px;  text-align:center;}
 877 #ub04id367{left:58px;  top:1010px; width:80px;  text-align:left;}
 878 #ub04id368{left:193px; top:1010px; width:77px;  text-align:center;}
 879 #ub04id369{left:269px; top:1010px; width:77px;  text-align:center;}
 880 #ub04id370{left:347px; top:1010px; width:77px;  text-align:center;}
 881 #ub04id371{left:468px; top:1010px; width:55px;  text-align:right;}
 882 #ub04id372{left:544px; top:1010px; width:78px;  text-align:center;}
 883 #ub04id373{left:622px; top:1010px; width:11px;  text-align:center;}
 884 #ub04id374{left:633px; top:1010px; width:77px;  text-align:center;}
 885 #ub04id375{left:711px; top:1010px; width:11px;  text-align:center;}
 886 #ub04id376{left:721px; top:1010px; width:77px;  text-align:center;}
 887 #ub04id377{left:798px; top:1010px; width:12px;  text-align:center;}
 888 #ub04id378{left:824px; top:1010px; width:95px;  text-align:left;}
 889 #ub04id379{left:662px; top:1028px; width:113px;  text-align:left;}
 890 #ub04id380{left:798px; top:1028px; width:23px;  text-align:left;}
 891 #ub04id381{left:821px; top:1028px; width:98px;  text-align:left;}
 892 #ub04id382{left:15px;  top:1045px; width:89px;  text-align:left;}
 893 #ub04id383{left:104px; top:1045px; width:77px;  text-align:right;}
 894 #ub04id384{left:182px; top:1045px; width:87px;  text-align:left;}
 895 #ub04id385{left:269px; top:1045px; width:77px;  text-align:right;}
 896 #ub04id386{left:347px; top:1045px; width:87px;  text-align:left;}
 897 #ub04id387{left:434px; top:1045px; width:77px;  text-align:right;}
 898 #ub04id388{left:594px; top:1045px; width:170px;  text-align:left;}
 899 #ub04id389{left:790px; top:1045px; width:129px;  text-align:left;}
 900 #ub04id390{left:662px; top:1065px; width:113px;  text-align:left;}
 901 #ub04id391{left:798px; top:1065px; width:23px;  text-align:left;}
 902 #ub04id392{left:821px; top:1065px; width:98px;  text-align:left;}
 903 #ub04id393{left:15px;  top:1082px; width:89px;  text-align:left;}
 904 #ub04id394{left:104px; top:1082px; width:77px;  text-align:right;}
 905 #ub04id395{left:182px; top:1082px; width:87px;  text-align:left;}
 906 #ub04id396{left:269px; top:1082px; width:77px;  text-align:right;}
 907 #ub04id397{left:347px; top:1082px; width:87px;  text-align:left;}
 908 #ub04id398{left:434px; top:1082px; width:77px;  text-align:right;}
 909 #ub04id399{resize:none; left:512px; top:1036px; width:55px; height:60px; color: rgb(0,0,0); text-align:left;}
 910 #ub04id400{left:594px; top:1082px; width:170px;  text-align:left;}
 911 #ub04id401{left:790px; top:1082px; width:129px;  text-align:left;}
 912 #ub04id402{left:303px; top:1102px; width:20px;  text-align:center;}
 913 #ub04id403{left:324px; top:1102px; width:110px;  text-align:left;}
 914 #ub04id404{left:436px; top:1102px; width:132px;  text-align:right;}
 915 #ub04id405{left:622px; top:1102px; width:22px;  text-align:left;}
 916 #ub04id406{left:662px; top:1102px; width:113px;  text-align:left;}
 917 #ub04id407{left:798px; top:1102px; width:23px;  text-align:left;}
 918 #ub04id408{left:821px; top:1102px; width:98px;  text-align:left;}
 919 #ub04id409{left:72px;  top:1102px; width:209px;  text-align:left;}
 920 #ub04id410{left:303px; top:1120px; width:20px;  text-align:center;}
 921 #ub04id411{left:324px; top:1120px; width:110px;  text-align:left;}
 922 #ub04id412{left:436px; top:1120px; width:132px;  text-align:right;}
 923 #ub04id413{left:594px; top:1120px; width:170px;  text-align:left;}
 924 #ub04id414{left:790px; top:1120px; width:129px;  text-align:left;}
 925 #ub04id415{left:19px;  top:1120px; width:263px;  text-align:left;}
 926 #ub04id416{left:303px; top:1137px; width:20px;  text-align:center;}
 927 #ub04id417{left:324px; top:1137px; width:110px;  text-align:left;}
 928 #ub04id418{left:436px; top:1137px; width:132px;  text-align:right;}
 929 #ub04id419{left:622px; top:1137px; width:22px;  text-align:left;}
 930 #ub04id420{left:662px; top:1137px; width:113px;  text-align:left;}
 931 #ub04id421{left:821px; top:1137px; width:98px;  text-align:left;}
 932 #ub04id422{left:798px; top:1137px; width:23px;  text-align:left;}
 933 #ub04id423{left:19px;  top:1137px; width:263px;  text-align:left;}
 934 #ub04id424{left:303px; top:1155px; width:20px;  text-align:center;}
 935 #ub04id425{left:324px; top:1155px; width:110px;  text-align:left;}
 936 #ub04id426{left:436px; top:1155px; width:132px;  text-align:right;}
 937 #ub04id427{left:594px; top:1155px; width:170px;  text-align:left;}
 938 #ub04id428{left:790px; top:1155px; width:129px;  text-align:left;}
 939 #ub04id429{left:19px;  top:1155px; width:263px;  text-align:left;}
 940 </style>
 941 </head>
 942 <body onload="adjustForm();">
 943 <div class="container" id="formContainer">
 944 <?php if ($isAuthorized !== true) {?>
 945 <h3 class='formhide'><em><?php echo xlt('Claim Edit') ?> </em><button class="btn btn-xs btn-warning" onclick="myZoom()" ><?php echo xlt('Zoom'); ?></button></h3>
 946 <div class="navbar-fixed-top formhide" id='menu'>
 947 <?php if ($pid && $encounter) {?>
 948     <button class="btn btn-xs btn-success" onclick="disposeSave('form')" title=<?php echo xlt("Save for printing with form") ?>><?php echo xlt('Pdf With Form'); ?></button>
 949     <button class="btn btn-xs btn-success" onclick="disposeSave('noform')" title=<?php echo xlt("Save for printing to a pre printed sheet"); ?>><?php echo xlt('Pdf Without Form'); ?></button>
 950     <button class="btn btn-xs btn-success" onclick="postClaim('batch_save')" title=<?php echo xlt("Save claim for batch processing"); ?>><?php echo xlt('Save Claim'); ?></button>
 951     <?php } else {?>
 952     <button class="btn btn-xs btn-success" onclick="postClaim('payer_save')"><?php echo xlt('Save Payer'); ?></button>
 953     <?php } ?>
 954     <button class="btn btn-xs btn-danger" onclick="resetClaim()" title=<?php echo xlt("Reset claim form to Fee Sheet Version"); ?>><?php echo xlt('Reset Version'); ?></button>
 955     <button class="btn btn-info btn-xs" type="button" onclick="window.scrollTo(0, 0);$('#formhelp').toggle()"><?php echo xlt('Help'); ?></button>
 956     <button class="btn btn-xs btn-danger" onclick="cleanUp()"><?php echo xlt('Return'); ?></button>
 957 </div>
 958 <div id='formhelp' class='well' style='display:none; text-align:center; width: auto; margin: 5px auto;'>
 959     <h4>Help</h4>
 960      <div style='text-align:left;'>
 961         * <?php echo xlt('Many code items have a lookup/hint.'); ?>
 962         <?php echo xlt('Either type a search term in appropriate box or double click box to see available codes.'); ?><br>
 963         * <?php echo xlt('Double Clicking a NPI box will bring up a current Users dialog for providers.'); ?><br>
 964         * <?php echo xlt('PDF buttons will save, mark claim reviewed and download claim'); ?><br>
 965         * <?php echo xlt('Reset button resets the edited claim to the fee sheet version. If subsequently  saved, it will replace last claim version and be considered reviewed. Otherwise, claim is reset to fee sheet version.'); ?><br>
 966         * <?php echo xlt('Save button saves claim and marks reviewed'); ?><br>
 967         * <?php echo xlt('Return button simply returns, then refreshes billing manager'); ?><br><br>
 968     </div>
 969    <button class="btn btn-primary btn-xs" type="button" onclick="$('#formhelp').toggle()"><?php echo xlt('Dismiss Help'); ?></button>
 970 </div>
 971 <?php } ?>
 972 <div id="p1" class="pageArea" style="overflow: hidden; position: relative; width: 934px; height: 1210px;">
 973 <!-- Template background -->
 974 <div id="pg1" style="-webkit-user-select: none;"><img src="<?php echo $imgurl ?>/ub04.svg" id="frmbg" style="width:934px; height:1210px; background-color:white; -moz-transform:scale(1); z-index: 0;" /></div>
 975 <!-- Begin Form Data -->
 976 <form id="ub04Data">
 977 <input type="text"   maxlength="25"  id="ub04id1" value=""  title="2. PAY-TO NAME"  name="ub04Block_4"/>
 978 <input type="text"   maxlength="25"  id="ub04id2" value=""  title="1. BILLING PROVIDER NAME"  name="ub04Block_0"/>
 979 <input type="text"   maxlength="20"  id="ub04id3" value=""  title="3a. PATIENT CONTROL NUMBER"  name="ub04Block_8"/>
 980 <input type="text"   maxlength="25"  id="ub04id4" value=""  title="1. BILLING PROVIDER STREET ADDRESS"  name="ub04Block_1"/>
 981 <input type="text"   maxlength="25"  id="ub04id5" value=""  title="2. PAY-TO STREET ADDRESS"  name="ub04Block_5"/>
 982 <input type="text"   maxlength="24"  id="ub04id6" value=""  title="3b. MEDICAL/HEALTH RECORD NUMBER"  name="ub04Block_9"/>
 983 <input type="text"   maxlength="4"  id="ub04id7" value=""   title="4. TYPE OF BILL"  name="ub04Block_10"/>
 984 <input type="text"   maxlength="25"  id="ub04id8" value=""  title="1. BILLING PROVIDER CITY, STATE, ZIP"  name="ub04Block_2"/>
 985 <input type="text"   maxlength="25"  id="ub04id9" value=""  title="2. PAY-TO CITY, STATE, ZIP"  name="ub04Block_6"/>
 986 <input type="text"   maxlength="25"  id="ub04id10" value="" title="1. BILLING PROVIDER COUNTRY CODE, PHONE NUMBER"  name="ub04Block_3"/>
 987 <input type="text"   maxlength="25"  id="ub04id11" value="" title="2. PAY-TO COUNTRY CODE, PHONE NUMBER"  name="ub04Block_7"/>
 988 <input type="text"   maxlength="10"  id="ub04id12" value="" title="5. FEDERAL TAX NUMBER"  name="ub04Block_11"/>
 989 <input type="text" data-dp  maxlength="10"  id="ub04id13" value=""  title="6. STATEMENT COVERS PERIOD FROM DATE"  name="ub04Block_12"/>
 990 <input type="text" data-dp   maxlength="10"  id="ub04id14" value=""  title="6. STATEMENT COVERS PERIOD TO DATE"  name="ub04Block_13"/>
 991 <textarea  disabled maxlength="15"  id="ub04id15" title="7. RESERVED"  name="ub04Block_14"></textarea>
 992 <input type="text"   maxlength="19"  id="ub04id16" value="" title="8a. PATIENT IDENTIFIER"  name="ub04Block_15"/>
 993 <input type="text"   maxlength="40"  id="ub04id17" value="" title="9a. PATIENT STREET ADDRESS"  name="ub04Block_17"/>
 994 <input type="text"   maxlength="29"  id="ub04id18" value="" title="8b. PATIENT NAME"  name="ub04Block_16"/>
 995 <input type="text"   maxlength="30"  id="ub04id19" value="" title="9b. PATIENT CITY"  name="ub04Block_18"/>
 996 <input type="text"   maxlength="2"  id="ub04id20" value=""  title="9c. PATIENT STATE"  name="ub04Block_19"/>
 997 <input type="text"   maxlength="9"  id="ub04id21" value=""  title="9d. PATIENT ZIP CODE"  name="ub04Block_20"/>
 998 <input type="text"   maxlength="2"  id="ub04id22" value=""  title="9e. PATIENT COUNTRY CODE"  name="ub04Block_21"/>
 999 <input type="text"   maxlength="8"  id="ub04id23" value=""  title="10. PATIENT BIRTH DATE (MMDDYYYY)"  name="ub04Block_22"/>
1000 <input type="text"   maxlength="1"  id="ub04id24" value=""  title="11. PATIENT SEX"  name="ub04Block_23"/>
1001 <input type="text" data-dp   maxlength="10"  id="ub04id25" value=""  title="12. PATIENT ADMISSION/START OF CARE DATE (MMDDYY)"  name="ub04Block_24"/>
1002 <input type="text"   maxlength="2"  id="ub04id26" value=""  title="13. PATIENT ADMISSION HOUR"  name="ub04Block_25"/>
1003 <input type="text"   maxlength="1"  id="ub04id27" value=""  title="14. PATIENT PRIORITY (TYPE) OF VISIT"  name="ub04Block_26"/>
1004 <input type="text"   maxlength="1"  id="ub04id28" value=""  title="15. PATIENT POINT OF ORIGIN FOR ADMISSION OR VISIT"  name="ub04Block_27"/>
1005 <input type="text"   maxlength="2"  id="ub04id29" value=""  title="16. PATIENT DISCHARGE HOUR"  name="ub04Block_28"/>
1006 <input type="text"   maxlength="2"  id="ub04id30" value=""  title="17. PATIENT DISCHARGE STATUS"  name="ub04Block_29"/>
1007 <input type="text"   maxlength="2"  id="ub04id31" value=""  title="18. CONDITION CODE"  name="ub04Block_30"/>
1008 <input type="text"   maxlength="2"  id="ub04id32" value=""  title="19. CONDITION CODE"  name="ub04Block_31"/>
1009 <input type="text"   maxlength="2"  id="ub04id33" value=""  title="20. CONDITION CODE"  name="ub04Block_32"/>
1010 <input type="text"   maxlength="2"  id="ub04id34" value=""  title="21. CONDITION CODE"  name="ub04Block_33"/>
1011 <input type="text"   maxlength="2"  id="ub04id35" value=""  title="22. CONDITION CODE"  name="ub04Block_34"/>
1012 <input type="text"   maxlength="2"  id="ub04id36" value=""  title="23. CONDITION CODE"  name="ub04Block_35"/>
1013 <input type="text"   maxlength="2"  id="ub04id37" value=""  title="24. CONDITION CODE"  name="ub04Block_36"/>
1014 <input type="text"   maxlength="2"  id="ub04id38" value=""  title="25. CONDITION CODE"  name="ub04Block_37"/>
1015 <input type="text"   maxlength="2"  id="ub04id39" value=""  title="26. CONDITION CODE"  name="ub04Block_38"/>
1016 <input type="text"   maxlength="2"  id="ub04id40" value=""  title="27. CONDITION CODE"  name="ub04Block_39"/>
1017 <input type="text"   maxlength="2"  id="ub04id41" value=""  title="28. CONDITION CODE"  name="ub04Block_40"/>
1018 <input type="text"   maxlength="2"  id="ub04id42" value=""  title="29. ACCIDENT STATE"  name="ub04Block_41"/>
1019 <input type="text" disabled   id="ub04id43" value="" data-objref="520" title="30. RESERVED"  name="ub04Block_42"/>
1020 <input type="text"   maxlength="2"  id="ub04id44" value=""  title="31a. OCCURRENCE CODE"  name="ub04Block_43"/>
1021 <input type="text" data-dp   maxlength="10"  id="ub04id45" value=""  title="31a. OCCURRENCE DATE"  name="ub04Block_44"/>
1022 <input type="text"   maxlength="2"  id="ub04id46" value=""  title="32a. OCCURRENCE CODE"  name="ub04Block_45"/>
1023 <input type="text" data-dp   maxlength="10"  id="ub04id47" value=""  title="32a. OCCURRENCE DATE"  name="ub04Block_46"/>
1024 <input type="text"   maxlength="2"  id="ub04id48" value=""  title="33a. OCCURRENCE CODE"  name="ub04Block_47"/>
1025 <input type="text" data-dp   maxlength="10"  id="ub04id49" value=""  title="33a. OCCURRENCE DATE"  name="ub04Block_48"/>
1026 <input type="text"   maxlength="2"  id="ub04id50" value=""  title="34a. OCCURRENCE CODE"  name="ub04Block_49"/>
1027 <input type="text" data-dp  maxlength="10"  id="ub04id51" value=""  title="34a. OCCURRENCE DATE"  name="ub04Block_50"/>
1028 <input type="text"   maxlength="2"  id="ub04id52" value=""  title="35a. OCCURRENCE SPAN CODE"  name="ub04Block_59"/>
1029 <input type="text" data-dp   maxlength="10"  id="ub04id53" value=""  title="35a. OCCURRENCE SPAN DATE FROM"  name="ub04Block_60"/>
1030 <input type="text" data-dp  maxlength="10"  id="ub04id54" value=""  title="35a. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_61"/>
1031 <input type="text"   maxlength="2"  id="ub04id55" value=""  title="36a. OCCURRENCE SPAN CODE"  name="ub04Block_62"/>
1032 <input type="text" data-dp   maxlength="10"  id="ub04id56" value=""  title="36a. OCCURRENCE SPAN DATE FROM"  name="ub04Block_63"/>
1033 <input type="text" data-dp   maxlength="10"  id="ub04id57" value=""  title="36a. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_64"/>
1034 <input type="text" disabled  maxlength="8"  id="ub04id58" value=""  title="37a. RESERVED"  name="ub04Block_71"/>
1035 <input type="text"   maxlength="2"  id="ub04id59" value=""  title="31b. OCCURRENCE CODE"  name="ub04Block_51"/>
1036 <input type="text" data-dp  maxlength="10"  id="ub04id60" value=""  title="31b. OCCURRENCE DATE"  name="ub04Block_52"/>
1037 <input type="text"   maxlength="2"  id="ub04id61" value=""  title="32b. OCCURRENCE CODE"  name="ub04Block_53"/>
1038 <input type="text" data-dp  maxlength="10"  id="ub04id62" value=""  title="32b. OCCURRENCE DATE"  name="ub04Block_54"/>
1039 <input type="text"   maxlength="2"  id="ub04id63" value=""  title="33b. OCCURRENCE CODE"  name="ub04Block_55"/>
1040 <input type="text" data-dp  maxlength="10"  id="ub04id64" value=""  title="33b. OCCURRENCE DATE"  name="ub04Block_56"/>
1041 <input type="text"   maxlength="2"  id="ub04id65" value=""  title="34b. OCCURRENCE CODE"  name="ub04Block_57"/>
1042 <input type="text" data-dp   maxlength="10"  id="ub04id66" value=""  title="34b. OCCURRENCE DATE"  name="ub04Block_58"/>
1043 <input type="text"   maxlength="2"  id="ub04id67" value=""  title="35b. OCCURRENCE SPAN CODE"  name="ub04Block_65"/>
1044 <input type="text" data-dp   maxlength="10"  id="ub04id68" value=""  title="35b. OCCURRENCE SPAN DATE FROM"  name="ub04Block_66"/>
1045 <input type="text" data-dp   maxlength="10"  id="ub04id69" value=""  title="35b. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_67"/>
1046 <input type="text"   maxlength="2"  id="ub04id70" value=""  title="36b. OCCURRENCE SPAN CODE"  name="ub04Block_68"/>
1047 <input type="text" data-dp   maxlength="10"  id="ub04id71" value=""  title="36b. OCCURRENCE SPAN DATE FROM"  name="ub04Block_69"/>
1048 <input type="text" data-dp   maxlength="10"  id="ub04id72" value=""  title="36b. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_70"/>
1049 <input type="text" disabled  maxlength="8"  id="ub04id73" value=""  title="37b. RESERVED"  name="ub04Block_72"/>
1050 <input type="text"   maxlength="2"  id="ub04id74" value=""  title="39a. VALUE CODE"  name="ub04Block_74"/>
1051 <input type="text"   maxlength="9"  id="ub04id75" value=""  title="39a. VALUE AMOUNT"  name="ub04Block_75"/>
1052 <input type="text"   maxlength="2"  id="ub04id76" value=""  title="40a. VALUE CODE"  name="ub04Block_76"/>
1053 <input type="text"   maxlength="9"  id="ub04id77" value=""  title="40a. VALUE AMOUNT"  name="ub04Block_77"/>
1054 <input type="text"   maxlength="2"  id="ub04id78" value=""  title="41a. VALUE CODE"  name="ub04Block_78"/>
1055 <input type="text"   maxlength="9"  id="ub04id79" value=""  title="41a. VALUE AMOUNT"  name="ub04Block_79"/>
1056 <input type="text"   maxlength="2"  id="ub04id80" value=""  title="39b. VALUE CODE"  name="ub04Block_80"/>
1057 <input type="text"   maxlength="9"  id="ub04id81" value=""  title="39b. VALUE AMOUNT"  name="ub04Block_81"/>
1058 <input type="text"   maxlength="2"  id="ub04id82" value=""  title="40b. VALUE CODE"  name="ub04Block_82"/>
1059 <input type="text"   maxlength="9"  id="ub04id83" value=""  title="40b. VALUE AMOUNT"  name="ub04Block_83"/>
1060 <input type="text"   maxlength="2"  id="ub04id84" value=""  title="41b. VALUE CODE"  name="ub04Block_84"/>
1061 <input type="text"   maxlength="9"  id="ub04id85" value=""  title="41b. VALUE AMOUNT"  name="ub04Block_85"/>
1062 <input type="text"   maxlength="2"  id="ub04id86" value=""  title="39c. VALUE CODE"  name="ub04Block_86"/>
1063 <input type="text"   maxlength="9"  id="ub04id87" value=""  title="39c. VALUE AMOUNT"  name="ub04Block_87"/>
1064 <input type="text"   maxlength="2"  id="ub04id88" value=""  title="40c. VALUE CODE"  name="ub04Block_88"/>
1065 <input type="text"   maxlength="9"  id="ub04id89" value=""  title="40c. VALUE AMOUNT"  name="ub04Block_89"/>
1066 <input type="text"   maxlength="2"  id="ub04id90" value=""  title="41c. VALUE CODE"  name="ub04Block_90"/>
1067 <input type="text"   maxlength="9"  id="ub04id91" value=""  title="41c. VALUE AMOUNT"  name="ub04Block_91"/>
1068 <input type="text"   maxlength="2"  id="ub04id92" value=""  title="39d. VALUE CODE"  name="ub04Block_92"/>
1069 <input type="text"   maxlength="9"  id="ub04id93" value=""  title="39d. VALUE AMOUNT"  name="ub04Block_93"/>
1070 <input type="text"   maxlength="2"  id="ub04id94" value=""  title="40d. VALUE CODE"  name="ub04Block_94"/>
1071 <input type="text"   maxlength="9"  id="ub04id95" value=""  title="40d. VALUE AMOUNT"  name="ub04Block_95"/>
1072 <input type="text"   maxlength="2"  id="ub04id96" value=""  title="41d. VALUE CODE"  name="ub04Block_96"/>
1073 <input type="text"   maxlength="9"  id="ub04id97" value=""  title="41d. VALUE AMOUNT"  name="ub04Block_97"/>
1074 <textarea   id="ub04id98"  title="38. RESPONSIBLE PARTY NAME AND ADDRESS"  name="ub04Block_73"></textarea>
1075 <input type="text" class="revcode" maxlength="4"  id="ub04id99" value=""   title="42. REVENUE CODE, Line 1"  name="ub04Block_98"/>
1076 <input type="text"   maxlength="25"  id="ub04id100" value="" title="43. REVENUE DESCRIPTION, Line 1"  name="ub04Block_99"/>
1077 <input type="text"   maxlength="24"  id="ub04id101" value="" title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 1"  name="ub04Block_100"/>
1078 <input type="text"   maxlength="10"  id="ub04id102" value=""  title="45. SERVICE DATE, Line 1"  name="ub04Block_101"/>
1079 <input type="text"   maxlength="7"  id="ub04id103" value=""  title="46. SERVICE UNITS, Line 1"  name="ub04Block_102"/>
1080 <input type="text"   maxlength="9"  id="ub04id104" value=""  title="47. TOTAL CHARGES, Line 1"  name="ub04Block_103"/>
1081 <input type="text"   maxlength="9"  id="ub04id105" value=""  title="48. NON-COVERED CHARGES, Line 1"  name="ub04Block_104"/>
1082 <input type="text" disabled  maxlength="2"  id="ub04id106" value=""  title="49. RESERVED, Line 1"  name="ub04Block_105"/>
1083 <input type="text" class="revcode" maxlength="4"  id="ub04id107" value=""  title="42. REVENUE CODE, Line 2"  name="ub04Block_106"/>
1084 <input type="text"   maxlength="25"  id="ub04id108" value=""  title="43. REVENUE DESCRIPTION, Line 2"  name="ub04Block_107"/>
1085 <input type="text"   maxlength="24"  id="ub04id109" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 2"  name="ub04Block_108"/>
1086 <input type="text"   maxlength="10"  id="ub04id110" value=""  title="45. SERVICE DATE, Line 2"  name="ub04Block_109"/>
1087 <input type="text"   maxlength="7"  id="ub04id111" value=""  title="46. SERVICE UNITS, Line 2"  name="ub04Block_110"/>
1088 <input type="text"   maxlength="9"  id="ub04id112" value=""  title="47. TOTAL CHARGES, Line 2"  name="ub04Block_111"/>
1089 <input type="text"   maxlength="9"  id="ub04id113" value=""  title="48. NON-COVERED CHARGES, Line 2"  name="ub04Block_112"/>
1090 <input type="text" disabled  maxlength="2"  id="ub04id114" value=""  title="49. RESERVED, Line 2"  name="ub04Block_113"/>
1091 <input type="text"   maxlength="4"  id="ub04id115" value=""  title="42. REVENUE CODE, Line 3"  name="ub04Block_114"/>
1092 <input type="text"   maxlength="25"  id="ub04id116" value=""  title="43. REVENUE DESCRIPTION, Line 3"  name="ub04Block_115"/>
1093 <input type="text"   maxlength="24"  id="ub04id117" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 3"  name="ub04Block_116"/>
1094 <input type="text" class="revcode" maxlength="10"  id="ub04id118" value=""  title="45. SERVICE DATE, Line 3"  name="ub04Block_117"/>
1095 <input type="text"   maxlength="7"  id="ub04id119" value=""  title="46. SERVICE UNITS, Line 3"  name="ub04Block_118"/>
1096 <input type="text"   maxlength="9"  id="ub04id120" value=""  title="47. TOTAL CHARGES, Line 3"  name="ub04Block_119"/>
1097 <input type="text"   maxlength="9"  id="ub04id121" value=""  title="48. NON-COVERED CHARGES, Line 3"  name="ub04Block_120"/>
1098 <input type="text"  disabled maxlength="2"  id="ub04id122" value=""  title="49. RESERVED, Line 3"  name="ub04Block_121"/>
1099 <input type="text"   maxlength="4"  id="ub04id123" value=""  title="42. REVENUE CODE, Line 4"  name="ub04Block_122"/>
1100 <input type="text"   maxlength="25"  id="ub04id124" value=""  title="43. REVENUE DESCRIPTION, Line 4"  name="ub04Block_123"/>
1101 <input type="text"   maxlength="24"  id="ub04id125" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 4"  name="ub04Block_124"/>
1102 <input type="text"   maxlength="10"  id="ub04id126" value=""  title="45. SERVICE DATE, Line 4"  name="ub04Block_125"/>
1103 <input type="text"   maxlength="7"  id="ub04id127" value=""  title="46. SERVICE UNITS, Line 4"  name="ub04Block_126"/>
1104 <input type="text"   maxlength="9"  id="ub04id128" value=""  title="47. TOTAL CHARGES, Line 4"  name="ub04Block_127"/>
1105 <input type="text"   maxlength="9"  id="ub04id129" value=""  title="48. NON-COVERED CHARGES, Line 4"  name="ub04Block_128"/>
1106 <input type="text" disabled  maxlength="2"  id="ub04id130" value=""  title="49. RESERVED, Line 4"  name="ub04Block_129"/>
1107 <input type="text"   maxlength="4"  id="ub04id131" value=""  title="42. REVENUE CODE, Line 5"  name="ub04Block_130"/>
1108 <input type="text"   maxlength="25"  id="ub04id132" value=""  title="43. REVENUE DESCRIPTION, Line 5"  name="ub04Block_131"/>
1109 <input type="text"   maxlength="24"  id="ub04id133" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 5"  name="ub04Block_132"/>
1110 <input type="text"   maxlength="10"  id="ub04id134" value=""  title="45. SERVICE DATE, Line 5"  name="ub04Block_133"/>
1111 <input type="text"   maxlength="7"  id="ub04id135" value=""  title="46. SERVICE UNITS, Line 5"  name="ub04Block_134"/>
1112 <input type="text"   maxlength="9"  id="ub04id136" value=""  title="47. TOTAL CHARGES, Line 5"  name="ub04Block_135"/>
1113 <input type="text"   maxlength="9"  id="ub04id137" value=""  title="48. NON-COVERED CHARGES, Line 5"  name="ub04Block_136"/>
1114 <input type="text" disabled  maxlength="2"  id="ub04id138" value=""  title="49. RESERVED, Line 5"  name="ub04Block_137"/>
1115 <input type="text"   maxlength="4"  id="ub04id139" value=""  title="42. REVENUE CODE, Line 6"  name="ub04Block_138"/>
1116 <input type="text"   maxlength="25"  id="ub04id140" value=""  title="43. REVENUE DESCRIPTION, Line 6"  name="ub04Block_139"/>
1117 <input type="text"   maxlength="24"  id="ub04id141" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 6"  name="ub04Block_140"/>
1118 <input type="text"   maxlength="10"  id="ub04id142" value=""  title="45. SERVICE DATE, Line 6"  name="ub04Block_141"/>
1119 <input type="text"   maxlength="7"  id="ub04id143" value=""  title="46. SERVICE UNITS, Line 6"  name="ub04Block_142"/>
1120 <input type="text"   maxlength="9"  id="ub04id144" value=""  title="47. TOTAL CHARGES, Line 6"  name="ub04Block_143"/>
1121 <input type="text"   maxlength="9"  id="ub04id145" value=""  title="48. NON-COVERED CHARGES, Line 6"  name="ub04Block_144"/>
1122 <input type="text" disabled  maxlength="2"  id="ub04id146" value=""  title="49. RESERVED, Line 6"  name="ub04Block_145"/>
1123 <input type="text"   maxlength="4"  id="ub04id147" value=""  title="42. REVENUE CODE, Line 7"  name="ub04Block_146"/>
1124 <input type="text"   maxlength="25"  id="ub04id148" value=""  title="43. REVENUE DESCRIPTION, Line 7"  name="ub04Block_147"/>
1125 <input type="text"   maxlength="24"  id="ub04id149" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 7"  name="ub04Block_148"/>
1126 <input type="text"   maxlength="10"  id="ub04id150" value=""  title="45. SERVICE DATE, Line 7"  name="ub04Block_149"/>
1127 <input type="text"   maxlength="7"  id="ub04id151" value=""  title="46. SERVICE UNITS, Line 7"  name="ub04Block_150"/>
1128 <input type="text"   maxlength="9"  id="ub04id152" value=""  title="47. TOTAL CHARGES, Line 7"  name="ub04Block_151"/>
1129 <input type="text"   maxlength="9"  id="ub04id153" value=""  title="48. NON-COVERED CHARGES, Line 7"  name="ub04Block_152"/>
1130 <input type="text" disabled  maxlength="2"  id="ub04id154" value=""  title="49. RESERVED, Line 7"  name="ub04Block_153"/>
1131 <input type="text"   maxlength="4"  id="ub04id155" value=""  title="42. REVENUE CODE, Line 8"  name="ub04Block_154"/>
1132 <input type="text"   maxlength="25"  id="ub04id156" value=""  title="43. REVENUE DESCRIPTION, Line 8"  name="ub04Block_155"/>
1133 <input type="text"   maxlength="24"  id="ub04id157" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 8"  name="ub04Block_156"/>
1134 <input type="text"   maxlength="10"  id="ub04id158" value=""  title="45. SERVICE DATE, Line 8"  name="ub04Block_157"/>
1135 <input type="text"   maxlength="7"  id="ub04id159" value=""  title="46. SERVICE UNITS, Line 8"  name="ub04Block_158"/>
1136 <input type="text"   maxlength="9"  id="ub04id160" value=""  title="47. TOTAL CHARGES, Line 8"  name="ub04Block_159"/>
1137 <input type="text"   maxlength="9"  id="ub04id161" value=""  title="48. NON-COVERED CHARGES, Line 8"  name="ub04Block_160"/>
1138 <input type="text"   maxlength="2"  id="ub04id162" value=""  title="49. RESERVED, Line 8"  name="ub04Block_161"/>
1139 <input type="text"   maxlength="4"  id="ub04id163" value=""  title="42. REVENUE CODE, Line 9"  name="ub04Block_162"/>
1140 <input type="text"   maxlength="25"  id="ub04id164" value=""  title="43. REVENUE DESCRIPTION, Line 9"  name="ub04Block_163"/>
1141 <input type="text"   maxlength="24"  id="ub04id165" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 9"  name="ub04Block_164"/>
1142 <input type="text"   maxlength="10"  id="ub04id166" value=""  title="45. SERVICE DATE, Line 9"  name="ub04Block_165"/>
1143 <input type="text"   maxlength="7"  id="ub04id167" value=""  title="46. SERVICE UNITS, Line 9"  name="ub04Block_166"/>
1144 <input type="text"   maxlength="9"  id="ub04id168" value=""  title="47. TOTAL CHARGES, Line 9"  name="ub04Block_167"/>
1145 <input type="text"   maxlength="9"  id="ub04id169" value=""  title="48. NON-COVERED CHARGES, Line 9"  name="ub04Block_168"/>
1146 <input type="text" disabled  maxlength="2"  id="ub04id170" value=""  title="49. RESERVED, Line 9"  name="ub04Block_169"/>
1147 <input type="text"   maxlength="4"  id="ub04id171" value=""  title="42. REVENUE CODE, Line 10"  name="ub04Block_170"/>
1148 <input type="text"   maxlength="25"  id="ub04id172" value=""  title="43. REVENUE DESCRIPTION, Line 10"  name="ub04Block_171"/>
1149 <input type="text"   maxlength="24"  id="ub04id173" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 10"  name="ub04Block_172"/>
1150 <input type="text"   maxlength="10"  id="ub04id174" value=""  title="45. SERVICE DATE, Line 10"  name="ub04Block_173"/>
1151 <input type="text"   maxlength="7"  id="ub04id175" value=""  title="46. SERVICE UNITS, Line 10"  name="ub04Block_174"/>
1152 <input type="text"   maxlength="9"  id="ub04id176" value=""  title="47. TOTAL CHARGES, Line 10"  name="ub04Block_175"/>
1153 <input type="text"   maxlength="9"  id="ub04id177" value=""  title="48. NON-COVERED CHARGES, Line 10"  name="ub04Block_176"/>
1154 <input type="text"  disabled maxlength="2"  id="ub04id178" value=""  title="49. RESERVED, Line 10"  name="ub04Block_177"/>
1155 <input type="text"   maxlength="4"  id="ub04id179" value=""  title="42. REVENUE CODE, Line 11"  name="ub04Block_178"/>
1156 <input type="text"   maxlength="25"  id="ub04id180" value=""  title="43. REVENUE DESCRIPTION, Line 11"  name="ub04Block_179"/>
1157 <input type="text"   maxlength="24"  id="ub04id181" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 11"  name="ub04Block_180"/>
1158 <input type="text"   maxlength="10"  id="ub04id182" value=""  title="45. SERVICE DATE, Line 11"  name="ub04Block_181"/>
1159 <input type="text"   maxlength="7"  id="ub04id183" value=""  title="46. SERVICE UNITS, Line 11"  name="ub04Block_182"/>
1160 <input type="text"   maxlength="9"  id="ub04id184" value=""  title="47. TOTAL CHARGES, Line 11"  name="ub04Block_183"/>
1161 <input type="text"   maxlength="9"  id="ub04id185" value=""  title="48. NON-COVERED CHARGES, Line 11"  name="ub04Block_184"/>
1162 <input type="text" disabled  maxlength="2"  id="ub04id186" value=""  title="49. RESERVED, Line 11"  name="ub04Block_185"/>
1163 <input type="text"   maxlength="4"  id="ub04id187" value=""  title="42. REVENUE CODE, Line 12"  name="ub04Block_186"/>
1164 <input type="text"   maxlength="25"  id="ub04id188" value=""  title="43. REVENUE DESCRIPTION, Line 12"  name="ub04Block_187"/>
1165 <input type="text"   maxlength="24"  id="ub04id189" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 12"  name="ub04Block_188"/>
1166 <input type="text"   maxlength="10"  id="ub04id190" value=""  title="45. SERVICE DATE, Line 12"  name="ub04Block_189"/>
1167 <input type="text"   maxlength="7"  id="ub04id191" value=""  title="46. SERVICE UNITS, Line 12"  name="ub04Block_190"/>
1168 <input type="text"   maxlength="9"  id="ub04id192" value=""  title="47. TOTAL CHARGES, Line 12"  name="ub04Block_191"/>
1169 <input type="text"   maxlength="9"  id="ub04id193" value=""  title="48. NON-COVERED CHARGES, Line 12"  name="ub04Block_192"/>
1170 <input type="text" disabled  maxlength="2"  id="ub04id194" value=""  title="49. RESERVED, Line 12"  name="ub04Block_193"/>
1171 <input type="text"   maxlength="4"  id="ub04id195" value=""  title="42. REVENUE CODE, Line 13"  name="ub04Block_194"/>
1172 <input type="text"   maxlength="25"  id="ub04id196" value=""  title="43. REVENUE DESCRIPTION, Line 13"  name="ub04Block_195"/>
1173 <input type="text"   maxlength="24"  id="ub04id197" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 13"  name="ub04Block_196"/>
1174 <input type="text"   maxlength="10"  id="ub04id198" value=""  title="45. SERVICE DATE, Line 13"  name="ub04Block_197"/>
1175 <input type="text"   maxlength="7"  id="ub04id199" value=""  title="46. SERVICE UNITS, Line 13"  name="ub04Block_198"/>
1176 <input type="text"   maxlength="9"  id="ub04id200" value=""  title="47. TOTAL CHARGES, Line 13"  name="ub04Block_199"/>
1177 <input type="text"   maxlength="9"  id="ub04id201" value=""  title="48. NON-COVERED CHARGES, Line 13"  name="ub04Block_200"/>
1178 <input type="text" disabled  maxlength="2"  id="ub04id202" value=""  title="49. RESERVED, Line 13"  name="ub04Block_201"/>
1179 <input type="text"   maxlength="4"  id="ub04id203" value=""  title="42. REVENUE CODE, Line 14"  name="ub04Block_202"/>
1180 <input type="text"   maxlength="25"  id="ub04id204" value=""  title="43. REVENUE DESCRIPTION, Line 14"  name="ub04Block_203"/>
1181 <input type="text"   maxlength="24"  id="ub04id205" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 14"  name="ub04Block_204"/>
1182 <input type="text"   maxlength="10"  id="ub04id206" value=""  title="45. SERVICE DATE, Line 14"  name="ub04Block_205"/>
1183 <input type="text"   maxlength="7"  id="ub04id207" value=""  title="46. SERVICE UNITS, Line 14"  name="ub04Block_206"/>
1184 <input type="text"   maxlength="9"  id="ub04id208" value=""  title="47. TOTAL CHARGES, Line 14"  name="ub04Block_207"/>
1185 <input type="text"   maxlength="9"  id="ub04id209" value=""  title="48. NON-COVERED CHARGES, Line 14"  name="ub04Block_208"/>
1186 <input type="text"  disabled maxlength="2"  id="ub04id210" value=""  title="49. RESERVED, Line 14"  name="ub04Block_209"/>
1187 <input type="text"   maxlength="4"  id="ub04id211" value=""  title="42. REVENUE CODE, Line 15"  name="ub04Block_210"/>
1188 <input type="text"   maxlength="25"  id="ub04id212" value=""  title="43. REVENUE DESCRIPTION, Line 15"  name="ub04Block_211"/>
1189 <input type="text"   maxlength="24"  id="ub04id213" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 15"  name="ub04Block_212"/>
1190 <input type="text"   maxlength="10"  id="ub04id214" value=""  title="45. SERVICE DATE, Line 15"  name="ub04Block_213"/>
1191 <input type="text"   maxlength="7"  id="ub04id215" value=""  title="46. SERVICE UNITS, Line 15"  name="ub04Block_214"/>
1192 <input type="text"   maxlength="9"  id="ub04id216" value=""  title="47. TOTAL CHARGES, Line 15"  name="ub04Block_215"/>
1193 <input type="text"   maxlength="9"  id="ub04id217" value=""  title="48. NON-COVERED CHARGES, Line 15"  name="ub04Block_216"/>
1194 <input type="text" disabled  maxlength="2"  id="ub04id218" value=""  title="49. RESERVED, Line 15"  name="ub04Block_217"/>
1195 <input type="text"   maxlength="4"  id="ub04id219" value=""  title="42. REVENUE CODE, Line 16"  name="ub04Block_218"/>
1196 <input type="text"   maxlength="25"  id="ub04id220" value=""  title="43. REVENUE DESCRIPTION, Line 16"  name="ub04Block_219"/>
1197 <input type="text"   maxlength="24"  id="ub04id221" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 16"  name="ub04Block_220"/>
1198 <input type="text"   maxlength="10"  id="ub04id222" value=""  title="45. SERVICE DATE, Line 16"  name="ub04Block_221"/>
1199 <input type="text"   maxlength="7"  id="ub04id223" value=""  title="46. SERVICE UNITS, Line 16"  name="ub04Block_222"/>
1200 <input type="text"   maxlength="9"  id="ub04id224" value=""  title="47. TOTAL CHARGES, Line 16"  name="ub04Block_223"/>
1201 <input type="text"   maxlength="9"  id="ub04id225" value=""  title="48. NON-COVERED CHARGES, Line 16"  name="ub04Block_224"/>
1202 <input type="text" disabled  maxlength="2"  id="ub04id226" value=""  title="49. RESERVED, Line 16"  name="ub04Block_225"/>
1203 <input type="text"   maxlength="4"  id="ub04id227" value=""  title="42. REVENUE CODE, Line 17"  name="ub04Block_226"/>
1204 <input type="text"   maxlength="25"  id="ub04id228" value=""  title="43. REVENUE DESCRIPTION, Line 17"  name="ub04Block_227"/>
1205 <input type="text"   maxlength="24"  id="ub04id229" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 17"  name="ub04Block_228"/>
1206 <input type="text"   maxlength="10"  id="ub04id230" value=""  title="45. SERVICE DATE, Line 17"  name="ub04Block_229"/>
1207 <input type="text"   maxlength="7"  id="ub04id231" value=""  title="46. SERVICE UNITS, Line 17"  name="ub04Block_230"/>
1208 <input type="text"   maxlength="9"  id="ub04id232" value=""  title="47. TOTAL CHARGES, Line 17"  name="ub04Block_231"/>
1209 <input type="text"   maxlength="9"  id="ub04id233" value=""  title="48. NON-COVERED CHARGES, Line 17"  name="ub04Block_232"/>
1210 <input type="text" disabled  maxlength="2"  id="ub04id234" value=""  title="49. RESERVED, Line 17"  name="ub04Block_233"/>
1211 <input type="text"   maxlength="4"  id="ub04id235" value=""  title="42. REVENUE CODE, Line 18"  name="ub04Block_234"/>
1212 <input type="text"   maxlength="25"  id="ub04id236" value=""  title="43. REVENUE DESCRIPTION, Line 18"  name="ub04Block_235"/>
1213 <input type="text"   maxlength="24"  id="ub04id237" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 18"  name="ub04Block_236"/>
1214 <input type="text"   maxlength="10"  id="ub04id238" value=""  title="45. SERVICE DATE, Line 18"  name="ub04Block_237"/>
1215 <input type="text"   maxlength="7"  id="ub04id239" value=""  title="46. SERVICE UNITS, Line 18"  name="ub04Block_238"/>
1216 <input type="text"   maxlength="9"  id="ub04id240" value=""  title="47. TOTAL CHARGES, Line 18"  name="ub04Block_239"/>
1217 <input type="text"   maxlength="9"  id="ub04id241" value=""  title="48. NON-COVERED CHARGES, Line 18"  name="ub04Block_240"/>
1218 <input type="text" disabled  maxlength="2"  id="ub04id242" value=""  title="49. RESERVED, Line 18"  name="ub04Block_241"/>
1219 <input type="text"   maxlength="4"  id="ub04id243" value=""  title="42. REVENUE CODE, Line 19"  name="ub04Block_242"/>
1220 <input type="text"   maxlength="25"  id="ub04id244" value=""  title="43. REVENUE DESCRIPTION, Line 19"  name="ub04Block_243"/>
1221 <input type="text"   maxlength="24"  id="ub04id245" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 19"  name="ub04Block_244"/>
1222 <input type="text"   maxlength="10"  id="ub04id246" value=""  title="45. SERVICE DATE, Line 19"  name="ub04Block_245"/>
1223 <input type="text"   maxlength="7"  id="ub04id247" value=""  title="46. SERVICE UNITS, Line 19"  name="ub04Block_246"/>
1224 <input type="text"   maxlength="9"  id="ub04id248" value=""  title="47. TOTAL CHARGES, Line 19"  name="ub04Block_247"/>
1225 <input type="text"   maxlength="9"  id="ub04id249" value=""  title="48. NON-COVERED CHARGES, Line 19"  name="ub04Block_248"/>
1226 <input type="text" disabled  maxlength="2"  id="ub04id250" value=""  title="49. RESERVED, Line 19"  name="ub04Block_249"/>
1227 <input type="text"   maxlength="4"  id="ub04id251" value=""  title="42. REVENUE CODE, Line 20"  name="ub04Block_250"/>
1228 <input type="text"   maxlength="25"  id="ub04id252" value=""  title="43. REVENUE DESCRIPTION, Line 20"  name="ub04Block_251"/>
1229 <input type="text"   maxlength="24"  id="ub04id253" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 20"  name="ub04Block_252"/>
1230 <input type="text"   maxlength="10"  id="ub04id254" value=""  title="45. SERVICE DATE, Line 20"  name="ub04Block_253"/>
1231 <input type="text"   maxlength="7"  id="ub04id255" value=""  title="46. SERVICE UNITS, Line 20"  name="ub04Block_254"/>
1232 <input type="text"   maxlength="9"  id="ub04id256" value=""  title="47. TOTAL CHARGES, Line 20"  name="ub04Block_255"/>
1233 <input type="text"   maxlength="9"  id="ub04id257" value=""  title="48. NON-COVERED CHARGES, Line 20"  name="ub04Block_256"/>
1234 <input type="text" disabled  maxlength="2"  id="ub04id258" value=""  title="49. RESERVED, Line 20"  name="ub04Block_257"/>
1235 <input type="text"   maxlength="4"  id="ub04id259" value=""  title="42. REVENUE CODE, Line 21"  name="ub04Block_258"/>
1236 <input type="text"   maxlength="25"  id="ub04id260" value=""  title="43. REVENUE DESCRIPTION, Line 21"  name="ub04Block_259"/>
1237 <input type="text"   maxlength="24"  id="ub04id261" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 21"  name="ub04Block_260"/>
1238 <input type="text"   maxlength="10"  id="ub04id262" value=""  title="45. SERVICE DATE, Line 21"  name="ub04Block_261"/>
1239 <input type="text"   maxlength="7"  id="ub04id263" value=""  title="46. SERVICE UNITS, Line 21"  name="ub04Block_262"/>
1240 <input type="text"   maxlength="9"  id="ub04id264" value=""  title="47. TOTAL CHARGES, Line 21"  name="ub04Block_263"/>
1241 <input type="text"   maxlength="9"  id="ub04id265" value=""  title="48. NON-COVERED CHARGES, Line 21"  name="ub04Block_264"/>
1242 <input type="text" disabled  maxlength="2"  id="ub04id266" value=""  title="49. RESERVED, Line 21"  name="ub04Block_265"/>
1243 <input type="text"   maxlength="4"  id="ub04id267" value=""  title="42. REVENUE CODE, Line 22"  name="ub04Block_266"/>
1244 <input type="text"   maxlength="25"  id="ub04id268" value=""  title="43. REVENUE DESCRIPTION, Line 22"  name="ub04Block_267"/>
1245 <input type="text"   maxlength="24"  id="ub04id269" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 22"  name="ub04Block_268"/>
1246 <input type="text"   maxlength="10"  id="ub04id270" value=""  title="45. SERVICE DATE, Line 22"  name="ub04Block_269"/>
1247 <input type="text"   maxlength="7"  id="ub04id271" value=""  title="46. SERVICE UNITS, Line 22"  name="ub04Block_270"/>
1248 <input type="text"   maxlength="9"  id="ub04id272" value=""  title="47. TOTAL CHARGES, Line 22"  name="ub04Block_271"/>
1249 <input type="text"   maxlength="9"  id="ub04id273" value=""  title="48. NON-COVERED CHARGES, Line 22"  name="ub04Block_272"/>
1250 <input type="text" disabled  maxlength="2"  id="ub04id274" value=""  title="49. RESERVED, Line 22"  name="ub04Block_273"/>
1251 <input type="text"    id="ub04id275" value=""  title="42. REVENUE CODE, Line 23"  name="ub04Block_274"/>
1252 <input type="text"   maxlength="3"  id="ub04id276" value=""  title="43. CLAIM PAGE NUMBER"  name="ub04Block_275"/>
1253 <input type="text"   maxlength="3"  id="ub04id277" value=""  title="43. TOTAL NUMBER OF CLAIM PAGES"  name="ub04Block_276"/>
1254 <input type="text"    id="ub04id278" value=""  title="45. CREATION DATE, Line 23"  name="ub04Block_277"/>
1255 <input type="text"    id="ub04id279" value=""  title="47. TOTAL OF TOTAL CHARGES, Line 23"  name="ub04Block_278"/>
1256 <input type="text"    id="ub04id280" value=""  title="48. TOTAL OF NON-COVERED CHARGES, Line 23"  name="ub04Block_279"/>
1257 <input type="text" disabled id="ub04id281" value=""  title="49. RESERVED, Line 23"  name="ub04Block_280"/>
1258 <input type="text"   maxlength="10"  id="ub04id282" value="" title="56. NATIONAL PROVIDER IDENTIFIER - BILLING PROVIDER"  name="ub04Block_299"/>
1259 <input type="text"   maxlength="23"  id="ub04id283" value="" title="50a. PRIMARY PAYER NAME"  name="ub04Block_281"/>
1260 <input type="text"   maxlength="15"  id="ub04id284" value="" title="51a. PRIMARY PAYER HEALTH PLAN ID"  name="ub04Block_282"/>
1261 <input type="text"   maxlength="1"  id="ub04id285" value="" title="52a. RELEASE OF INFORMATION CERTIFICATION INDICATOR, PRIMARY PAYER"  name="ub04Block_283"/>
1262 <input type="text"   maxlength="1"  id="ub04id286" value="" title="53a. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, PRIMARY PAYER"  name="ub04Block_284"/>
1263 <input type="text"   maxlength="10"  id="ub04id287" value="" title="54a. PRIMARY PAYER PRIOR PAYMENTS"  name="ub04Block_285"/>
1264 <input type="text"   maxlength="10"  id="ub04id288" value="" title="55a. PRIMARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_286"/>
1265 <input type="text"    id="ub04id289" value=""  title="57a. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_300"/>
1266 <input type="text"   maxlength="23"  id="ub04id290" value="" title="50b. SECONDARY PAYER NAME"  name="ub04Block_287"/>
1267 <input type="text"   maxlength="15"  id="ub04id291" value="" title="51b. SECONDARY PAYER HEALTH PLAN ID"  name="ub04Block_288"/>
1268 <input type="text"   maxlength="1"  id="ub04id292" value="" title="52b. RELEASE OF INFORMATION CERTIFICATION INDICATOR, SECONDARY PAYER"  name="ub04Block_289"/>
1269 <input type="text"   maxlength="1"  id="ub04id293" value="" title="53b. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, SECONDARY PAYER"  name="ub04Block_290"/>
1270 <input type="text"   maxlength="10"  id="ub04id294" value="" title="54b. SECONDARY PAYER PRIOR PAYMENTS"  name="ub04Block_291"/>
1271 <input type="text"   maxlength="10"  id="ub04id295" value="" title="55b. SECONDARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_292"/>
1272 <input type="text"    id="ub04id296" value="" title="57b. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_301"/>
1273 <input type="text"   maxlength="23"  id="ub04id297" value="" title="50c. TERTIARY PAYER NAME"  name="ub04Block_293"/>
1274 <input type="text"   maxlength="15"  id="ub04id298" value="" title="51c. TERTIARY PAYER HEALTH PLAN ID"  name="ub04Block_294"/>
1275 <input type="text"   maxlength="1"  id="ub04id299" value="" title="52c.RELEASE OF INFORMATION CERTIFICATION INDICATOR, TERTIARY PAYER"  name="ub04Block_295"/>
1276 <input type="text"   maxlength="1"  id="ub04id300" value="" title="53c. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, TERTIARY PAYER"  name="ub04Block_296"/>
1277 <input type="text"   maxlength="10"  id="ub04id301" value="" title="54c. TERTIARY PAYER PRIOR PAYMENTS"  name="ub04Block_297"/>
1278 <input type="text"   maxlength="10"  id="ub04id302" value="" title="55c. TERTIARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_298"/>
1279 <input type="text"    id="ub04id303" value="" title="57c. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_302"/>
1280 <input type="text"   maxlength="25"  id="ub04id304" value="" title="58a. INSURED'S NAME - PRIMARY PLAN"  name="ub04Block_303"/>
1281 <input type="text"   maxlength="2"  id="ub04id305" value="" title="59a. PATIENT'S RELATIONSHIP TO INSURED - PRIMARY PLAN"  name="ub04Block_304"/>
1282 <input type="text"   maxlength="20"  id="ub04id306" value="" title="60a. INSURED'S UNIQUE IDENTIFIER - PRIMARY PLAN"  name="ub04Block_305"/>
1283 <input type="text"   maxlength="14"  id="ub04id307" value="" title="61a. INSURED'S GROUP NAME - PRIMARY PLAN"  name="ub04Block_306"/>
1284 <input type="text"   maxlength="17"  id="ub04id308" value="" title="62a. INSURANCE GROUP NUMBER - PRIMARY PLAN"  name="ub04Block_307"/>
1285 <input type="text"   maxlength="25"  id="ub04id309" value="" title="58b. INSURED'S NAME - SECONDARY PLAN"  name="ub04Block_308"/>
1286 <input type="text"   maxlength="2"  id="ub04id310" value="" title="59b. PATIENT'S RELATIONSHIP TO INSURED - SECONDARY PLAN"  name="ub04Block_309"/>
1287 <input type="text"   maxlength="20"  id="ub04id311" value="" title="60b. INSURED'S UNIQUE IDENTIFIER - SECONDARY PLAN"  name="ub04Block_310"/>
1288 <input type="text"   maxlength="14"  id="ub04id312" value="" title="61b. INSURED'S GROUP NAME - SECONDARY PLAN"  name="ub04Block_311"/>
1289 <input type="text"   maxlength="17"  id="ub04id313" value="" title="62b. INSURANCE GROUP NUMBER - SECONDARY PLAN"  name="ub04Block_312"/>
1290 <input type="text"   maxlength="25"  id="ub04id314" value="" title="58c. INSURED'S NAME - TERTIARY PLAN"  name="ub04Block_313"/>
1291 <input type="text"   maxlength="2"  id="ub04id315" value="" title="59c. PATIENT'S RELATIONSHIP TO INSURED - TERTIARY PLAN"  name="ub04Block_314"/>
1292 <input type="text"   maxlength="20"  id="ub04id316" value="" title="60c. INSURED'S UNIQUE IDENTIFIER - TERTIARY PLAN"  name="ub04Block_315"/>
1293 <input type="text"   maxlength="14"  id="ub04id317" value="" title="61c. INSURED'S GROUP NAME - TERTIARY PLAN"  name="ub04Block_316"/>
1294 <input type="text"   maxlength="17"  id="ub04id318" value="" title="62c. INSURANCE GROUP NUMBER - TERTIARY PLAN"  name="ub04Block_317"/>
1295 <input type="text"   maxlength="30"  id="ub04id319" value="" title="63a. TREATMENT AUTHORIZATION CODES - PRIMARY PLAN"  name="ub04Block_318"/>
1296 <input type="text"   maxlength="26"  id="ub04id320" value="" title="64a. DOCUMENT CONTROL NUMBER (DCN) - PRIMARY PLAN"  name="ub04Block_319"/>
1297 <input type="text"   maxlength="25"  id="ub04id321" value="" title="65a. INSURED'S EMPLOYER NAME - PRIMARY PLAN"  name="ub04Block_320"/>
1298 <input type="text"   maxlength="30"  id="ub04id322" value="" title="63b. TREATMENT AUTHORIZATION CODES - SECONDARY PLAN"  name="ub04Block_321"/>
1299 <input type="text"   maxlength="26"  id="ub04id323" value="" title="64b. DOCUMENT CONTROL NUMBER (DCN) - SECONDARY PLAN"  name="ub04Block_322"/>
1300 <input type="text"   maxlength="25"  id="ub04id324" value="" title="65b. INSURED'S EMPLOYER NAME - SECONDARY PLAN"  name="ub04Block_323"/>
1301 <input type="text"   maxlength="30"  id="ub04id325" value="" title="63c. TREATMENT AUTHORIZATION CODES - TERTIARY PLAN"  name="ub04Block_324"/>
1302 <input type="text"   maxlength="26"  id="ub04id326" value="" title="64c. DOCUMENT CONTROL NUMBER (DCN) - TERTIARY PLAN"  name="ub04Block_325"/>
1303 <input type="text"   maxlength="25"  id="ub04id327" value="" title="65c. INSURED'S EMPLOYER NAME - TERTIARY PLAN"  name="ub04Block_326"/>
1304 <input type="text"   maxlength="7"  id="ub04id328" value="" title="67. PRINCIPAL DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_328"/>
1305 <input type="text"   maxlength="1"  id="ub04id329" value="" title="67. PRINCIPAL DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_329"/>
1306 <input type="text"   maxlength="7"  id="ub04id330" value="" title="67A. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_330"/>
1307 <input type="text"   maxlength="1"  id="ub04id331" value="" title="67A. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_331"/>
1308 <input type="text"   maxlength="7"  id="ub04id332" value="" title="67B. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_332"/>
1309 <input type="text"   maxlength="1"  id="ub04id333" value="" title="67B. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_333"/>
1310 <input type="text"   maxlength="7"  id="ub04id334" value="" title="67C. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_334"/>
1311 <input type="text"   maxlength="1"  id="ub04id335" value="" title="67C. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_335"/>
1312 <input type="text"   maxlength="7"  id="ub04id336" value="" title="67D. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_336"/>
1313 <input type="text"   maxlength="1"  id="ub04id337" value="" title="67D. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_337"/>
1314 <input type="text"   maxlength="7"  id="ub04id338" value="" title="67E. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_338"/>
1315 <input type="text"   maxlength="1"  id="ub04id339" value="" title="67E. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_339"/>
1316 <input type="text"   maxlength="7"  id="ub04id340" value="" title="67F. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_340"/>
1317 <input type="text"   maxlength="1"  id="ub04id341" value="" title="67F. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_341"/>
1318 <input type="text"   maxlength="7"  id="ub04id342" value="" title="67G. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_342"/>
1319 <input type="text"   maxlength="1"  id="ub04id343" value="" title="67G. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_343"/>
1320 <input type="text"   maxlength="7"  id="ub04id344" value="" title="67H. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_344"/>
1321 <input type="text"   maxlength="1"  id="ub04id345" value="" title="67H. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_345"/>
1322 <input type="text" disabled  maxlength="8"  id="ub04id346" value="" title="68. RESERVED"  name="ub04Block_364"/>
1323 <input type="text"   maxlength="1"  id="ub04id347" value="" title="66. DIAGNOSIS AND PROCEDURE CODE QUALIFIER (ICD VERSION INDICATOR)"  name="ub04Block_327"/>
1324 <input type="text"   maxlength="7"  id="ub04id348" value="" title="67I. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_346"/>
1325 <input type="text"   maxlength="1"  id="ub04id349" value="" title="67I. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_347"/>
1326 <input type="text"   maxlength="7"  id="ub04id350" value="" title="67J. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_348"/>
1327 <input type="text"   maxlength="1"  id="ub04id351" value="" title="67J. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_349"/>
1328 <input type="text"   maxlength="7"  id="ub04id352" value="" title="67K. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_350"/>
1329 <input type="text"   maxlength="1"  id="ub04id353" value="" title="67K. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_351"/>
1330 <input type="text"   maxlength="7"  id="ub04id354" value="" title="67L. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_352"/>
1331 <input type="text"   maxlength="1"  id="ub04id355" value="" title="67L. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_353"/>
1332 <input type="text"   maxlength="7"  id="ub04id356" value="" title="67M. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_354"/>
1333 <input type="text"   maxlength="1"  id="ub04id357" value="" title="67M. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_355"/>
1334 <input type="text"   maxlength="7"  id="ub04id358" value="" title="67N. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_356"/>
1335 <input type="text"   maxlength="1"  id="ub04id359" value="" title="67N. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_357"/>
1336 <input type="text"   maxlength="7"  id="ub04id360" value="" title="67O. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_358"/>
1337 <input type="text"   maxlength="1"  id="ub04id361" value="" title="67O. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_359"/>
1338 <input type="text"   maxlength="7"  id="ub04id362" value="" title="67P. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_360"/>
1339 <input type="text"   maxlength="7"  id="ub04id363" value="" title="67Q. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_362"/>
1340 <input type="text"   maxlength="1"  id="ub04id364" value="" title="67Q. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_363"/>
1341 <input type="text" disabled  maxlength="9"  id="ub04id365" value="" title="68. RESERVED"  name="ub04Block_365"/>
1342 <input type="text"   maxlength="1"  id="ub04id366" value="" title="67P. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_361"/>
1343 <input type="text"   maxlength="7"  id="ub04id367" value="" title="69. ADMITTING DIAGNOSIS CODE"  name="ub04Block_366"/>
1344 <input type="text"   maxlength="7"  id="ub04id368" value="" title="70a. PATIENT'S REASON FOR VISIT"  name="ub04Block_367"/>
1345 <input type="text"   maxlength="7"  id="ub04id369" value="" title="70b. PATIENT'S REASON FOR VISIT"  name="ub04Block_368"/>
1346 <input type="text"   maxlength="7"  id="ub04id370" value="" title="70c. PATIENT'S REASON FOR VISIT"  name="ub04Block_369"/>
1347 <input type="text"   maxlength="4"  id="ub04id371" value="" title="71. PROSPECTIVE PAYMENT SYSTEM (PPS) CODE"  name="ub04Block_370"/>
1348 <input type="text"   maxlength="7"  id="ub04id372" value="" title="72a. EXTERNAL CAUSE OF INJURY (ECI) CODE AND POA INDICATOR"  name="ub04Block_371"/>
1349 <input type="text"   maxlength="1"  id="ub04id373" value="" title="72a. EXTERNAL CAUSE OF INJURY (ECI) PRESENT ON ADMISSION INDICATOR "  name="ub04Block_372"/>
1350 <input type="text"   maxlength="7"  id="ub04id374" value="" title="72b. EXTERNAL CAUSE OF INJURY (ECI) CODE AND POA INDICATOR"  name="ub04Block_373"/>
1351 <input type="text"   maxlength="1"  id="ub04id375" value="" title="72b. EXTERNAL CAUSE OF INJURY (ECI) PRESENT ON ADMISSION INDICATOR "  name="ub04Block_374"/>
1352 <input type="text"   maxlength="7"  id="ub04id376" value="" title="72c. EXTERNAL CAUSE OF INJURY (ECI) CODE AND POA INDICATOR"  name="ub04Block_375"/>
1353 <input type="text"   maxlength="1"  id="ub04id377" value="" title="72c. EXTERNAL CAUSE OF INJURY (ECI) PRESENT ON ADMISSION INDICATOR "  name="ub04Block_376"/>
1354 <input type="text" disabled  maxlength="9"  id="ub04id378" value="" title="73. RESERVED"  name="ub04Block_377"/>
1355 <input type="text" class="user"  maxlength="11"  id="ub04id379" value="" title="76. ATTENDING PROVIDER NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_391"/>
1356 <input type="text"   maxlength="2"  id="ub04id380" value="" title="76. ATTENDING PROVIDER SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_392"/>
1357 <input type="text"   maxlength="9"  id="ub04id381" value="" title="76. ATTENDING PROVIDER SECONDARY IDENTIFIER"  name="ub04Block_393"/>
1358 <input type="text"   maxlength="7"  id="ub04id382" value="" title="74. PRINCIPAL PROCEDURE CODE"  name="ub04Block_378"/>
1359 <input type="text"   maxlength="10"  id="ub04id383" value="" title="74. PRINCIPAL PROCEDURE DATE"  name="ub04Block_379"/>
1360 <input type="text"   maxlength="7"  id="ub04id384" value="" title="74a. OTHER PROCEDURE CODE"  name="ub04Block_380"/>
1361 <input type="text"   maxlength="10"  id="ub04id385" value="" title="74a. OTHER PROCEDURE DATE"  name="ub04Block_381"/>
1362 <input type="text"   maxlength="7"  id="ub04id386" value="" title="74b. OTHER PROCEDURE CODE"  name="ub04Block_382"/>
1363 <input type="text"   maxlength="10"  id="ub04id387" value="" title="74b. OTHER PROCEDURE DATE"  name="ub04Block_383"/>
1364 <input type="text"   maxlength="16"  id="ub04id388" value="" title="76. ATTENDING PROVIDER LAST NAME"  name="ub04Block_394"/>
1365 <input type="text"   maxlength="12"  id="ub04id389" value="" title="76. ATTENDING PROVIDER FIRST NAME"  name="ub04Block_395"/>
1366 <input type="text" class="user" maxlength="11"  id="ub04id390" value="" title="77. OPERATING PHYSICIAN NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_396"/>
1367 <input type="text"   maxlength="2"  id="ub04id391" value="" title="77. OPERATING PHYSICIAN SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_397"/>
1368 <input type="text"   maxlength="9"  id="ub04id392" value="" title="77. OPERATING PHYSICIAN SECONDARY IDENTIFIER"  name="ub04Block_398"/>
1369 <input type="text"   maxlength="7"  id="ub04id393" value="" title="74c. OTHER PROCEDURE CODE"  name="ub04Block_384"/>
1370 <input type="text"   maxlength="10"  id="ub04id394" value="" title="74c. OTHER PROCEDURE DATE"  name="ub04Block_385"/>
1371 <input type="text"   maxlength="7"  id="ub04id395" value="" title="74d. OTHER PROCEDURE CODE"  name="ub04Block_386"/>
1372 <input type="text"   maxlength="10"  id="ub04id396" value="" title="74d. OTHER PROCEDURE DATE"  name="ub04Block_387"/>
1373 <input type="text"   maxlength="7"  id="ub04id397" value="" title="74e. OTHER PROCEDURE CODE"  name="ub04Block_388"/>
1374 <input type="text"   maxlength="10"  id="ub04id398" value="" title="74d. OTHER PROCEDURE DATE"  name="ub04Block_389"/>
1375 <textarea disabled maxlength="16"  id="ub04id399" title="75. RESERVED"  name="ub04Block_390"></textarea>
1376 <input type="text"   maxlength="16"  id="ub04id400" value="" title="77. OPERATING PHYSICIAN LAST NAME"  name="ub04Block_399"/>
1377 <input type="text"   maxlength="12"  id="ub04id401" value="" title="77. OPERATING PHYSICIAN FIRST NAME"  name="ub04Block_400"/>
1378 <input type="text"   maxlength="2"  id="ub04id402" value="" title="81a. CODE QUALIFIER"  name="ub04Block_417"/>
1379 <input type="text"   maxlength="10"  id="ub04id403" value="" title="81a. CODE"  name="ub04Block_421"/>
1380 <input type="text"   maxlength="12"  id="ub04id404" value="" title="81a. VALUE"  name="ub04Block_425"/>
1381 <input type="text"   maxlength="2"  id="ub04id405" value="" title="79. OTHER PROVIDER TYPE QUALIFIER"  name="ub04Block_401"/>
1382 <input type="text" class="user" maxlength="11"  id="ub04id406" value="" title="78. OTHER PROVIDER NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_402"/>
1383 <input type="text"   maxlength="2"  id="ub04id407" value="" title="78. OTHER PROVIDER SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_403"/>
1384 <input type="text"   maxlength="9"  id="ub04id408" value="" title="78. OTHER PROVIDER SECONDARY IDENTIFIER"  name="ub04Block_404"/>
1385 <input type="text"   maxlength="19"  id="ub04id409" value="" title="80. REMARKS"  name="ub04Block_413"/>
1386 <input type="text"   maxlength="2"  id="ub04id410" value="" title="81b. CODE QUALIFIER"  name="ub04Block_418"/>
1387 <input type="text"   maxlength="10"  id="ub04id411" value="" title="81b. CODE"  name="ub04Block_422"/>
1388 <input type="text"   maxlength="12"  id="ub04id412" value="" title="81b. VALUE"  name="ub04Block_426"/>
1389 <input type="text"   maxlength="16"  id="ub04id413" value="" title="78. OTHER PROVIDER LAST NAME"  name="ub04Block_405"/>
1390 <input type="text"   maxlength="12"  id="ub04id414" value="" title="78. OTHER PROVIDER FIRST NAME"  name="ub04Block_406"/>
1391 <input type="text"   maxlength="24"  id="ub04id415" value="" title="80. REMARKS"  name="ub04Block_414"/>
1392 <input type="text"   maxlength="2"  id="ub04id416" value="" title="81c. CODE QUALIFIER"  name="ub04Block_419"/>
1393 <input type="text"   maxlength="10"  id="ub04id417" value="" title="81c. CODE"  name="ub04Block_423"/>
1394 <input type="text"   maxlength="12"  id="ub04id418" value="" title="81c. VALUE"  name="ub04Block_427"/>
1395 <input type="text"   maxlength="2"  id="ub04id419" value="" title="79. OTHER PROVIDER TYPE QUALIFIER"  name="ub04Block_407"/>
1396 <input type="text" class="user"  maxlength="11"  id="ub04id420" value="" title="79. OTHER PROVIDER NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_408"/>
1397 <input type="text"   maxlength="9"  id="ub04id421" value="" title="79. OTHER PROVIDER SECONDARY IDENTIFIER"  name="ub04Block_410"/>
1398 <input type="text"   maxlength="2"  id="ub04id422" value="" title="79. OTHER PROVIDER SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_409"/>
1399 <input type="text"   maxlength="24"  id="ub04id423" value="" title="80. REMARKS"  name="ub04Block_415"/>
1400 <input type="text"   maxlength="2"  id="ub04id424" value="" title="81d. CODE QUALIFIER"  name="ub04Block_420"/>
1401 <input type="text"   maxlength="10"  id="ub04id425" value="" title="81d. CODE"  name="ub04Block_424"/>
1402 <input type="text"   maxlength="12"  id="ub04id426" value="" title="81d. VALUE"  name="ub04Block_428"/>
1403 <input type="text"   maxlength="16"  id="ub04id427" value="" title="79. OTHER PROVIDER LAST NAME"  name="ub04Block_411"/>
1404 <input type="text"   maxlength="12"  id="ub04id428" value="" title="79. OTHER PROVIDER FIRST NAME"  name="ub04Block_412"/>
1405 <input type="text"   maxlength="24"  id="ub04id429" value="" title="80. REMARKS"  name="ub04Block_416"/>
1406 </form>
1407 <!-- End Form Data -->
1408 </div>
1409 </div>
1410 </body>
1411 </html>